titleSouth African Veterinary Council - Regulations
http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines2018-03-20T01:56:20+00:00Joomla! - Open Source Content ManagementGuidelines - Management Of Patients With Immune Mediated Haemolytic Anaemia2009-09-02T11:21:49+00:002009-09-02T11:21:49+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/243-guidelines-management-of-patients-with-immune-mediated-haemolytic-anaemiaAdministratorwebmaster@savc.org.za<div class="feed-description"><p><strong><span style="text-decoration: underline;">
<p align="center">GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH IMMUNE MEDIATED HAEMOLYTIC ANAEMIA</p>
<p align="justify"> </p>
</span></strong></p>
<p align="justify">Author: Dr L.L. van der Merwe</p>
<p align="justify">With Input from Prof A. Leisewitz, Dr A. Goddard, and Dr F. Kettner</p>
<p align="justify">All of the Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, Onderstepoort.</p>
<p><strong></strong></p>
<p align="justify">This article will primarily revolve around the management of dogs with immune mediated destruction of erythrocytes secondary to babesiosis and will discuss the ideal monitoring parameters for such a case. The other causes of secondary immune mediated haemolytic anaemia (IMHA) (drugs, bacterial infections, neoplasia, etc) or primary IMHA will not be discussed in any detail. They all show very similar presenting clinical sign, the disease will progress in a similar manner, and also develop similar complications although the long term prognosis does vary.</p>
<p align="justify">Immune mediated haemolytic anaemia secondary to babesiosis will be self evident due to the temporal relationship with finding the parasite on a stained bloodsmear, or a history of the patient having recently being treated for babesiosis. Other secondary causes of IMHA may be much more insidious and present a greater diagnostic challenge.</p>
<p><strong>
<p align="justify">A.</p>
</strong></p>
<p align="justify">The management and monitoring of a patient with haemolytic disease is a combination of both clinical and laboratory parameters.</p>
<p><strong>
<p align="justify">1. Initial Patient Evaluation</p>
</strong></p>
<p align="justify"> </p>
<p align="justify">Clinical signs are attributable to:</p>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The degree of anaemia</td>
</tr>
</tbody>
</table>
<p align="justify">Clinical signs attributable to anaemia will depend on the acuteness of the erythrocyte destruction and whether compensatory mechanisms have been activated.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The type of anaemia /haemolysis</td>
</tr>
</tbody>
</table>
<p align="justify">Intravascular haemolysis</p>
<p align="justify">Hallmarks of this form of haemolysis include haemoglobinuria, haemoglobinaemia (red serum) and splenomegaly.</p>
<p><span style="text-decoration: underline;">
<p align="justify">Extravascular haemolysis</p>
</span></p>
<p align="justify">Haemoglobinaemia and haemoglobinuria are absent as the erythrocytes aer lysed within phagocytes, but splenomegally is usually present.</p>
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<td width="100%" valign="top">Multi-systemic signs</td>
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<p align="justify">Multi-systemic organ disease and/or failure may develop due to excessive or imbalanced cytokine secretion, the generation of free oxygen radicals, immune system dysregulation, endothelial damage, activation of the coagulation cascade, and disturbances in oxygen supply to the tissues. These complications may occur in any haemolytic disease be it babesiosis or primary IMHA.</p>
<p><strong>
<p align="justify">2. Laboratory Evaluation</p>
<ol type="a">
<li>Full Evaluation of a blood smear</li>
</ol> </strong></p>
<p align="justify">There is more to the evaluation of a blood smear than simply finding <em>Babesia</em> parasites:</p>
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<td width="100%" valign="top">Blood smears should always be good quality (with straight edges and well defined shoulders and a feather edge) and be properly stained for evaluation. Diagnosis may easily be missed if the quality of the smear is poor!</td>
</tr>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Red cell regenerative capacity should be assessed. Reticulocytes and normoblasts cause anisocytosis and polychromasia with an increase in red cell distribution width (RDW). The smear may appear non-regenerative in acute severe haemolysis as the bone marrow storage pool is used and a 2-3 day lag phase exists between red cell destruction and the appearance of a bone marrow response in the peripheral circulation. Acute babesiosis also seems to suppress the red cell regenerative capacity and the degree of regeneration in the presence of an active parasitaemia is usually inappropriate. Strong red cell regenerative responses should, however, be seen soon after elimination of the <em>Babesia</em> parasite.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Evaluate for concurrent <em>Ehrlichia</em> infection<em> </em>in both the monocytes as well as the neutrophils. It is important to note that phagocytosed erythrocytes and parasites may resemble <em>Ehrlichia</em> morulae.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The presence of spherocytosis (small, dark staining, round erythrocytes without central pallor) indicates an immune-mediated process in red cell destruction. When more than 40-60% of red cells are spherocytes, a diagnosis of IMHA is strongly supported (although IMHA can be present with lower percentages).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Haemolytic disease, with or without a concurrent <em>Babesia</em> infection is an inflammatory process. Any inflammatory process in the body may induce a neutrophila with a left shift (increased band cells). This is usually a regenerative left shift and the presence thereof does not imply bacterial infection. <em>Babesia</em> infection without an inflammatory leukogram may be indicative of concurrent immunosuppressive disease (such as <em>Ehrlichia</em>, or distemper).</td>
</tr>
</tbody>
</table>
<p align="justify"> </p>
<ol type="a">
<li>Packed cell volume (PCV):</li>
</ol>
<p align="justify">The PCV is a percentage value obtained by centrifuging a blood sample in a micro-pipette tube. The haematocrit, on the other hand, is a haematology analyser calculated value based on red cell number and mean red cell volume.</p>
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<td width="100%" valign="top">Determine the initial PCV at time of presentation. Whether a blood transfusion is necessary is usually not a decision based on PCV alone. Other factors such as the clinical state of the dog, the availability of blood, the chronicity of the condition, ISA positivity with ongoing erythrocyte destruction, and financial constraints will all affect this choice. The initial PCV value is also useful to assist with the evaluation of response to therapy. Dogs that have chronic disease where the anaemia evolved slowly will be better able to cope with a low PCV than dogs that have experienced a rapid decrease in the PCV.</td>
</tr>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The buffy-coat can also be smeared to evaluate the white blood cells for the presence of Ehrlichia.</td>
</tr>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Together with the PCV the serum component should also be assessed.</td>
</tr>
</tbody>
</table>
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<tbody>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If the sample is collected atraumatically, any red discolouration of the serum can be interpreted as intravascular haemolysis.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Total serum proteins (TSP) can be read by a refractometer. In young animals especially, verminosis is commonly occurs concurrently with babesiosis. A low TSP is an indication for a whole blood rather than a packed red cell transfusion, or for patient support with intravenous colloids administration.</td>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Mild to moderate hypoalbuminaemia is common in babesiosis because of the inflammatory nature of the disease and the loss of albumin through damaged endothelium. However, the estimation of the TSP by a refractometer is a crude estimation of the albumin levels as increases in globulins (common in <em>Babesia</em> infection) may mask the decrease in albumin.</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">c) In-Saline Agglutination (ISA)/ Autoagglutination:</p>
</strong></p>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Auto-agglutination is the result of the spontaneous aggregation of erythrocytes due to the presence of erythrocyte-membrane bound immunoglobulins. These antibodies may be primary or acquired auto-antibodies. Autoagglutination must be differentiated from rouleaux formation, which occurs when erythrocytes stack together due to electrostatic forces caused by the presence of serum proteins (fibrinogen and acute phase globulins).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The ISA test is performed to check for an immune mediated reaction against the erythrocytes. Rouleaux will be dispersed by the addition of saline. False positives occur if insufficient saline is used to dilute the sample. The standard test procedure involves adding 1 drop of whole anti-coagulated blood to 6 drops of saline. This mixture should be well mixed. The slide must be evaluated under a microscope at 400 ´ magnification (no oil immersion) with low light intensity and the light condenser dropped low.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A negative ISA test does not, however, imply that IMHA is absent as the test is relatively crude. The interpretation can be graded according to the size of the aggregates.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">It should be noted that the ISA test is useful and should be done in all cases of babesiosis at initial presentation together with the PCV. If it is not done at initial presentation, it is imperative that it be performed in all cases that respond poorly to therapy.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">It should also be noted that response to immunosuppressive treatment for IMHA should be based on a rise in PCV and not by the resolution of a positive ISA reaction. Most dogs that respond well to immunosuppression (as seen by a rising PCV) will remain ISA positive for a few days despite good recovery. This occurs because the antibodies responsible for agglutination have a long half-life and will need to be cleared from circulation before the positive ISA reaction resolves. Therefore treat the PCV and not the ISA reaction.</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">d) Coombs’ Test</p>
</strong></p>
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<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Although a threshold density of erythrocyte membrane bound antibodies is required to cause auto-agglutination, the sensitized reticuloendothelial system of the body can recognize cells that are marked (opsonised) with only very few antibodies.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The Coombs’ test is more sensitive than ISA in the diagnosis of IMHA as it involves the incubation of washed patient erythrocytes with serum containing anti-immunoglobulin antibodies which increases cross-linkages and thus potentiating agglutination at lower immunoglobulin levels. This test is indicated in patients exhibiting clinical and laboratory signs of regenerative anaemia with or without spherocytosis that do not show any evidence of blood loss. There is no need to perform this test if the patient is ISA positive.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">As both the Coombs’ and ISA tests are affected by foreign erythrocytes, they must be performed <span style="text-decoration: underline;">PRIOR </span>to any blood transfusion.</td>
</tr>
</tbody>
</table>
<p><strong></strong></p>
<p align="justify">The initial evaluation of a patient with a <span style="text-decoration: underline;">haemolytic disease</span> and laboratory monitoring is a synthesis of the abovementioned simple laboratory tests, a good clinical examination and common sense.</p>
<p align="justify">Always remember that TRENDS are all important and one-off examinations are often misleading.</p>
<p><strong>
<p align="justify">3. Patient Monitoring</p>
</strong></p>
<p align="justify">The complications associated with the haemolytic disease, be it babesiosis or primary or secondary IMHA, are generally due to a combination of anaemia and the systemic inflammatory reaction. The organs that are most frequently secondarily affected include the lungs (causing acute respiratory distress syndrome - ARDS), kidneys (causing acute renal failure - ARF), liver (causing icterus), erythrocytes (causing secondary IMHA), the brain (causing cerebral signs) and coagulation disorders (including pulmonary thromboembolism - PTE).</p>
<p align="justify">The assessment and monitoring must therefore include criteria that would evaluate these organ systems:</p>
<ol type="i"> <strong> </strong>
<li><strong>Lungs:</strong></li>
<strong> </strong>
<p align="justify">Monitor for sudden increases in respiratory <span style="text-decoration: underline;">rate and depth</span>, referred breath sounds and increased effort of respiration. Always remember that very anaemic <em>Babesia</em> infected dogs always have profound blood gas and acid-base disturbances, which should resolve with blood transfusion. If respiratory signs worsen or improve only to suddenly deteriorate again following transfusion, consider ARDS or pulmonary thromboembolism. Increases in rate and depth are signs on an early decrease in pulmonary compliance due to fluid accumulation in the interstitium. By the time rales are auscultated the fluid accumulation is severe the alveoli are flooded, which may be a very poor prognostic sign. Radiographs, although helpful in confirming pathology do not take the place of a careful clinical evaluation as clinical changes will precede radiographic changes.</p>
<p align="justify">The initial monitoring plan of a sick <em>Babesia</em> patient should include frequent (hourly) assessment of the respiratory rate for at least the first 6 hours. This parameter is a simple yet sensitive indicator of decreased pulmonary function.</p>
<strong> </strong>
<li><strong>Kidneys:</strong></li>
<strong> </strong>
<p align="justify">Monitor for <span style="text-decoration: underline;">urine production</span>, especially in haemoconcentrated babesiosis cases which very frequently present with ARF. Oliguria or anuria will <span style="text-decoration: underline;">precede </span>the development of azotaemia (increases in urea and creatinine). Note that haemolysis will cause an increase in urea without a linear increase in creatinine. As such <span style="text-decoration: underline;">urea used alone is a poor indicator of renal function</span> in this scenario and should always be used with creatinine or creatinine should be used alone.</p>
<strong><span style="text-decoration: underline;"> </span></strong>
<li><strong><span style="text-decoration: underline;">Secondary/acquired IMHA:</span></strong></li>
<strong><span style="text-decoration: underline;"> </span></strong>
<p align="justify">The majority of clinically ill babesiosis infected dogs are Coombs’ positive and it is estimated that about 20% of cases seen at Outpatients section of the Onderstepoort Veterinary Academic Hospital are ISA positive at the time of <em>Babesia</em> diagnosis. The decision on how to proceed with these cases is based on the PCV at the time of diagnosis, ISA positivity, the colour of the serum, and the general clinical condition of the animal Many of these patients are ISA negative within 24 – 48 hours and thus do not require a long tapering course of prednisilone as eradication of the parasite has removed the trigger or the initial test was a false positive.</p>
<p align="justify">Occasionally a case can develop into a severe and clinically important secondary IMHA where auto-antibodies have developed against normal erythrocyte membrane antigens. These patients are challenging to manage and require aggressive therapy often with multiple transfusions and strong immunosuppressive therapy of several months duration.</p>
<li>Follow-up evaluation</li>
</ol>
<p align="justify">It is important to request a re-evaluation of the dog the day following initial therapy. Uncomplicated cases will show a distinct improvement in habitus and clinical signs, although the PCV may still be quite low or even the same as the previous day. The parasitized cells are removed from circulation and the PCV may fall between 1-7% six hours after injecting of the babesiacidal agent. This percentage will obviously be affected by the regenerative capacity of the patient and the initial parasite density.</p>
<p align="justify">The monitoring of a patient with haemolytic disease /true IMHA involves the following basic in-house laboratory tests:</p>
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</table>
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<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A repeat <strong>blood smear</strong> evaluation is essential to evaluate for regeneration and spherocytosis.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ensure that the <strong>ISA</strong> test has been performed accurately.<strong> </strong>ISA must be evaluated microscopically. If the patient is positive at a 1:6 dilution with saline, increase the ration to a 1:20. A true ISA will still be positive whereas strong rouleaux will become negative.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Determine if the<strong> PCV </strong>is stable, decreasing or increasing. This parameter must be interpreted together with the identification of regeneration on the blood smear. IMHA cases are usually highly regenerative. Good regeneration with a stable PCV indicates ongoing erythrocyte destruction. Concomitant disease or chronic inflammation may decrease the regenerative capacity.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Evaluate <strong>serum colour </strong>for haemolysis</td>
</tr>
</tbody>
</table>
<p align="justify">A typical regimen for a mild, babesiosis induced IMHA is a tapering dose of 2mg/kg decreasing to 0.5 mg/kg over 7 days.</p>
<p><strong>
<p align="justify">B. Primary IMHA</p>
</strong></p>
<p align="justify">The diagnosis of primary IMHA is challenging as it requires the <span style="text-decoration: underline;">exclusion</span> of all possible secondary causes, which are numerous.</p>
<p align="justify">To simplify matters an abridged version of causes follows.</p>
<p align="justify">Infectious: – ensure that the patient has been thoroughly examined for any chronic infections: endocarditis, osteomyelitis, discospondylitis, urinary tract infections, prostatitis, pyometra, dirofilaria, ehrlichia</p>
<p align="justify">Drugs: - many medications are capable inducing IMHA. Vaccinations, especially rabies are probable causes if given less than 3-4 weeks previously. Potentiated sulpha drugs are major inducers of auto-immune reactions and may cause immune mediated thrombocytopaenia, IMHA, immune mediated polyarthritis and keratoconjunctivitis sicca (KCS). Cephalosporins and penicillins are also predisposed.</p>
<p align="justify">Neoplastic : Neoplastic cells may express non self antigens on their cell surfaces and as such may induce a variety on immune mediated conditions e.g. Thymoma induced Myaesthenia gravis.</p>
<p><strong> </strong></p>
<p align="justify">A thorough, logical and often costly clinical and diagnostic plan is required to eliminate secondary causes.</p>
<p align="justify">Primary IMHA is more resistant to therapy and will require very gradual tapering with duration of therapy up to 6 months. In large breed dogs it is often advisable to add azathioprine early in the course of therapy to allow a reduction in the prednisilone dosage and thus decrease the side effects.</p>
<p align="justify">These dosage regimens are not a hard and fast rule but will be modified according to regular patient and haematology re-evaluations. These parameters should be re-assessed after each dosage reduction of the immunosuppressive therapy and at regular 2-3 week intervals to ensure that the condition is resolving. Often the prednisilone is tapered too rapidly and the haemolysis starts up again. If no monitoring is performed the animal will only present when the PCV is so low that it is once again causing clinical signs.</p>
<p><strong></strong></p>
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<td colspan="4" valign="top"><strong> </strong>
<p align="center"><strong><br /></strong></p>
<strong> </strong>
<p align="center"><strong>TABLE OF DRUGS WHICH CAN BE USED TO MANAGE IMHA ( summarized)</strong></p>
<strong> </strong>
<p align="center"><strong></strong></p>
</td>
</tr>
<tr>
<td width="18%" valign="top"><strong> </strong>
<p align="justify"><strong>Drug</strong></p>
</td>
<td width="20%" valign="top"><strong> </strong>
<p align="justify"><strong>Mechanism</strong></p>
</td>
<td width="33%" valign="top"><strong> </strong>
<p align="justify"><strong>Regimen</strong></p>
</td>
<td width="28%" valign="top"><strong> </strong>
<p align="justify"><strong>Side effects/ comments</strong></p>
<strong> </strong>
<p align="justify"><strong></strong></p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Prednisilone</p>
</td>
<td width="20%" valign="top">
<p align="center">* Blocks macrophages</p>
<p align="center">* Decreases antibody production</p>
<p align="center"> </p>
<p align="center">* 4-5 days to effect</p>
</td>
<td width="33%" valign="top">
<p align="center">2-4 mg.kg/ d is immunosuppressive</p>
<p align="center">(&gt; 20kg = 3mg/day, &lt;20kg = 4mg/kg/d … BSA effect)</p>
<p align="center">taper initially by decr. dose by 50% every 2-3 weeks until 1mg/kg/day.</p>
<p align="center">Maintain for 4 weeks, then decrease to 0.5mg/kgoid for 4w then 0,5mg/kg alt days for 4-8 weeks.</p>
</td>
<td width="28%" valign="top">
<p align="center">* Large breed dogs may develop severe muscle wasting and weakness. Advise combination with azathioprine to allow dose reduction ASAP.</p>
<p align="center">* Small breeds show more typical cushingoid side effects of weight gain and pu/pd</p>
<p align="center">* GIT ulceration (prevent with MisoprostilÒ )</p>
<p align="center"> </p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Azathioprine</p>
<p align="center">( AzapressÒ )</p>
</td>
<td width="20%" valign="top">
<p align="center">* Suppresses T cell function</p>
<p align="center">* 2 weeks to peak effect</p>
</td>
<td width="33%" valign="top">
<p align="center">Initiating dose of 1-2 mg/kg / day then maintenance at 1 -2 mg/kg every alternate day</p>
<p align="center">( often alternating with prednisilone)</p>
<p align="center"> </p>
</td>
<td width="28%" valign="top">
<p align="center">* Contraindicated in cats</p>
<p align="center">* May cause pancreatitis and bone marrow suppression</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Cyclophosphamide</p>
<p align="center">(EndoxanÒ )</p>
</td>
<td width="20%" valign="top">
<p align="center">* Anti-neoplastic agent</p>
<p align="center">* Antibody and lymphocyte suppression</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">50mg/m<sup>2</sup> first 4 days of each week for maximum of 4-6 weeks.</p>
<p align="center"> </p>
<p align="center">Not recommended by the author</p>
</td>
<td width="28%" valign="top">
<p align="center">* severe bone marrow suppression</p>
<p align="center">* haemorrhagic sterile cystitis</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">HIVGG</p>
<p align="center">(Human Intravenous Gamma globulin)</p>
</td>
<td width="20%" valign="top">
<p align="center">* Saturates Macrophage Fc receptors.</p>
<p align="center">* Immediate effect</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">Indicated for erythrophagocytic IMHA.</p>
<p align="center">0.5 – 1.5 g/kg iv over 4-6 hours</p>
<p align="center"> </p>
</td>
<td width="28%" valign="top">
<p align="center">* Very Expensive</p>
<p align="center">* Bridging therapy</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Cyclosporin</p>
<p align="center"> </p>
</td>
<td width="20%" valign="top">
<p align="center">* Inhibits amplification of immune reaction</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">5 – 15 mg/kg / day</p>
<p align="center">serum levels &gt; 200ng/ml</p>
</td>
<td width="28%" valign="top">
<p align="center">* Expensive</p>
<p align="center">* Bridging therapy</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Danazol</p>
</td>
<td width="20%" valign="top">
<p align="center">* Decreases RBC fragility</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">5mg/kg tid</p>
</td>
<td width="28%" valign="top">
<p align="center">* For chronic management</p>
</td>
</tr>
</tbody>
</table>
<p>References:</p>
<ol>
<li> <ol>
<li>Jacobson LS, Reyers F et al. Changes in haematocrit after treatment of uncomplicated canine babesiosis: a comparison between diminazine and trypan blue, and an evaluation of the influence of parasitaemia. <em>Journal of the South African Veterinary Association </em>1996 vol. 67 (2) pp 95 – 105</li>
<li>Grundy SA, Barton C. Influence of drug treatment on survival of dogs with immune mediated haemolytic anaemia: 88 cases (1989 – 1999) <em>Journal of the American Veterinary Medical Assosciation. </em>2001 vol. 218 (4)543 – 545</li>
<li>Kellerman DL, Bruyette DS. Intravenous Human Immunoglobulin for the Treatment of Immune-Mediated Hemolytic Anemia in 13 Dogs. <em>Journal of Veterinary Internal Medicine </em>1997 vol 11 (6) pp 327 – 332</li>
<li>Reimer ME, Troy GC, Warnick LD .Immune –Mediated Hemolytic Anemia: 70 cases (1988 – 1996<em>). Journal of the American Animal Hospital Association</em> 1999 Vol. 35 pp 384 – 391</li>
<li>Slappendal R.J. Interpretation of tests for immune mediated blood diseases. In <em>Kirks Current Veterinary Therapeutics</em> X (Eds) Kirk and Bonagura. pg: 498 – 50.</li>
<li>Stewart A.F., Feldman B.F. Immune mediated hemolytic anemia. Part I. Clinical Entity, Diagnosis, and Treatment Theory. <em>Compendium on Continuing Education for the Practicing Veterinarian</em> 1993 Vol. 15 (11) pp 1479 – 1993</li>
<li>Stewart A.F., Feldman B.F. Immune mediated hemolytic anemia. Part II. An Overview. <em>Compendium on Continuing Education for the Practicing Veterinarian </em>1993 Vol15 (3) pp 372 – 381</li>
<li>Vaughn Scott T, Jacobson L.S. et al Systemic Inflammatory Response syndrome and multiple-organ damage /dysfunction in complicated canine babesiosis. <em>Journal of the South African Veterinary Association </em>2001 vol 72 (3) pp 158 – 162</li>
</ol></li>
</ol></div><div class="feed-description"><p><strong><span style="text-decoration: underline;">
<p align="center">GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH IMMUNE MEDIATED HAEMOLYTIC ANAEMIA</p>
<p align="justify"> </p>
</span></strong></p>
<p align="justify">Author: Dr L.L. van der Merwe</p>
<p align="justify">With Input from Prof A. Leisewitz, Dr A. Goddard, and Dr F. Kettner</p>
<p align="justify">All of the Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, Onderstepoort.</p>
<p><strong></strong></p>
<p align="justify">This article will primarily revolve around the management of dogs with immune mediated destruction of erythrocytes secondary to babesiosis and will discuss the ideal monitoring parameters for such a case. The other causes of secondary immune mediated haemolytic anaemia (IMHA) (drugs, bacterial infections, neoplasia, etc) or primary IMHA will not be discussed in any detail. They all show very similar presenting clinical sign, the disease will progress in a similar manner, and also develop similar complications although the long term prognosis does vary.</p>
<p align="justify">Immune mediated haemolytic anaemia secondary to babesiosis will be self evident due to the temporal relationship with finding the parasite on a stained bloodsmear, or a history of the patient having recently being treated for babesiosis. Other secondary causes of IMHA may be much more insidious and present a greater diagnostic challenge.</p>
<p><strong>
<p align="justify">A.</p>
</strong></p>
<p align="justify">The management and monitoring of a patient with haemolytic disease is a combination of both clinical and laboratory parameters.</p>
<p><strong>
<p align="justify">1. Initial Patient Evaluation</p>
</strong></p>
<p align="justify"> </p>
<p align="justify">Clinical signs are attributable to:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The degree of anaemia</td>
</tr>
</tbody>
</table>
<p align="justify">Clinical signs attributable to anaemia will depend on the acuteness of the erythrocyte destruction and whether compensatory mechanisms have been activated.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The type of anaemia /haemolysis</td>
</tr>
</tbody>
</table>
<p align="justify">Intravascular haemolysis</p>
<p align="justify">Hallmarks of this form of haemolysis include haemoglobinuria, haemoglobinaemia (red serum) and splenomegaly.</p>
<p><span style="text-decoration: underline;">
<p align="justify">Extravascular haemolysis</p>
</span></p>
<p align="justify">Haemoglobinaemia and haemoglobinuria are absent as the erythrocytes aer lysed within phagocytes, but splenomegally is usually present.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Multi-systemic signs</td>
</tr>
</tbody>
</table>
<p align="justify">Multi-systemic organ disease and/or failure may develop due to excessive or imbalanced cytokine secretion, the generation of free oxygen radicals, immune system dysregulation, endothelial damage, activation of the coagulation cascade, and disturbances in oxygen supply to the tissues. These complications may occur in any haemolytic disease be it babesiosis or primary IMHA.</p>
<p><strong>
<p align="justify">2. Laboratory Evaluation</p>
<ol type="a">
<li>Full Evaluation of a blood smear</li>
</ol> </strong></p>
<p align="justify">There is more to the evaluation of a blood smear than simply finding <em>Babesia</em> parasites:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Blood smears should always be good quality (with straight edges and well defined shoulders and a feather edge) and be properly stained for evaluation. Diagnosis may easily be missed if the quality of the smear is poor!</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Red cell regenerative capacity should be assessed. Reticulocytes and normoblasts cause anisocytosis and polychromasia with an increase in red cell distribution width (RDW). The smear may appear non-regenerative in acute severe haemolysis as the bone marrow storage pool is used and a 2-3 day lag phase exists between red cell destruction and the appearance of a bone marrow response in the peripheral circulation. Acute babesiosis also seems to suppress the red cell regenerative capacity and the degree of regeneration in the presence of an active parasitaemia is usually inappropriate. Strong red cell regenerative responses should, however, be seen soon after elimination of the <em>Babesia</em> parasite.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Evaluate for concurrent <em>Ehrlichia</em> infection<em> </em>in both the monocytes as well as the neutrophils. It is important to note that phagocytosed erythrocytes and parasites may resemble <em>Ehrlichia</em> morulae.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The presence of spherocytosis (small, dark staining, round erythrocytes without central pallor) indicates an immune-mediated process in red cell destruction. When more than 40-60% of red cells are spherocytes, a diagnosis of IMHA is strongly supported (although IMHA can be present with lower percentages).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Haemolytic disease, with or without a concurrent <em>Babesia</em> infection is an inflammatory process. Any inflammatory process in the body may induce a neutrophila with a left shift (increased band cells). This is usually a regenerative left shift and the presence thereof does not imply bacterial infection. <em>Babesia</em> infection without an inflammatory leukogram may be indicative of concurrent immunosuppressive disease (such as <em>Ehrlichia</em>, or distemper).</td>
</tr>
</tbody>
</table>
<p align="justify"> </p>
<ol type="a">
<li>Packed cell volume (PCV):</li>
</ol>
<p align="justify">The PCV is a percentage value obtained by centrifuging a blood sample in a micro-pipette tube. The haematocrit, on the other hand, is a haematology analyser calculated value based on red cell number and mean red cell volume.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Determine the initial PCV at time of presentation. Whether a blood transfusion is necessary is usually not a decision based on PCV alone. Other factors such as the clinical state of the dog, the availability of blood, the chronicity of the condition, ISA positivity with ongoing erythrocyte destruction, and financial constraints will all affect this choice. The initial PCV value is also useful to assist with the evaluation of response to therapy. Dogs that have chronic disease where the anaemia evolved slowly will be better able to cope with a low PCV than dogs that have experienced a rapid decrease in the PCV.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The buffy-coat can also be smeared to evaluate the white blood cells for the presence of Ehrlichia.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Together with the PCV the serum component should also be assessed.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If the sample is collected atraumatically, any red discolouration of the serum can be interpreted as intravascular haemolysis.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Total serum proteins (TSP) can be read by a refractometer. In young animals especially, verminosis is commonly occurs concurrently with babesiosis. A low TSP is an indication for a whole blood rather than a packed red cell transfusion, or for patient support with intravenous colloids administration.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Mild to moderate hypoalbuminaemia is common in babesiosis because of the inflammatory nature of the disease and the loss of albumin through damaged endothelium. However, the estimation of the TSP by a refractometer is a crude estimation of the albumin levels as increases in globulins (common in <em>Babesia</em> infection) may mask the decrease in albumin.</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">c) In-Saline Agglutination (ISA)/ Autoagglutination:</p>
</strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Auto-agglutination is the result of the spontaneous aggregation of erythrocytes due to the presence of erythrocyte-membrane bound immunoglobulins. These antibodies may be primary or acquired auto-antibodies. Autoagglutination must be differentiated from rouleaux formation, which occurs when erythrocytes stack together due to electrostatic forces caused by the presence of serum proteins (fibrinogen and acute phase globulins).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The ISA test is performed to check for an immune mediated reaction against the erythrocytes. Rouleaux will be dispersed by the addition of saline. False positives occur if insufficient saline is used to dilute the sample. The standard test procedure involves adding 1 drop of whole anti-coagulated blood to 6 drops of saline. This mixture should be well mixed. The slide must be evaluated under a microscope at 400 ´ magnification (no oil immersion) with low light intensity and the light condenser dropped low.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A negative ISA test does not, however, imply that IMHA is absent as the test is relatively crude. The interpretation can be graded according to the size of the aggregates.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">It should be noted that the ISA test is useful and should be done in all cases of babesiosis at initial presentation together with the PCV. If it is not done at initial presentation, it is imperative that it be performed in all cases that respond poorly to therapy.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">It should also be noted that response to immunosuppressive treatment for IMHA should be based on a rise in PCV and not by the resolution of a positive ISA reaction. Most dogs that respond well to immunosuppression (as seen by a rising PCV) will remain ISA positive for a few days despite good recovery. This occurs because the antibodies responsible for agglutination have a long half-life and will need to be cleared from circulation before the positive ISA reaction resolves. Therefore treat the PCV and not the ISA reaction.</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">d) Coombs’ Test</p>
</strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Although a threshold density of erythrocyte membrane bound antibodies is required to cause auto-agglutination, the sensitized reticuloendothelial system of the body can recognize cells that are marked (opsonised) with only very few antibodies.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The Coombs’ test is more sensitive than ISA in the diagnosis of IMHA as it involves the incubation of washed patient erythrocytes with serum containing anti-immunoglobulin antibodies which increases cross-linkages and thus potentiating agglutination at lower immunoglobulin levels. This test is indicated in patients exhibiting clinical and laboratory signs of regenerative anaemia with or without spherocytosis that do not show any evidence of blood loss. There is no need to perform this test if the patient is ISA positive.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">As both the Coombs’ and ISA tests are affected by foreign erythrocytes, they must be performed <span style="text-decoration: underline;">PRIOR </span>to any blood transfusion.</td>
</tr>
</tbody>
</table>
<p><strong></strong></p>
<p align="justify">The initial evaluation of a patient with a <span style="text-decoration: underline;">haemolytic disease</span> and laboratory monitoring is a synthesis of the abovementioned simple laboratory tests, a good clinical examination and common sense.</p>
<p align="justify">Always remember that TRENDS are all important and one-off examinations are often misleading.</p>
<p><strong>
<p align="justify">3. Patient Monitoring</p>
</strong></p>
<p align="justify">The complications associated with the haemolytic disease, be it babesiosis or primary or secondary IMHA, are generally due to a combination of anaemia and the systemic inflammatory reaction. The organs that are most frequently secondarily affected include the lungs (causing acute respiratory distress syndrome - ARDS), kidneys (causing acute renal failure - ARF), liver (causing icterus), erythrocytes (causing secondary IMHA), the brain (causing cerebral signs) and coagulation disorders (including pulmonary thromboembolism - PTE).</p>
<p align="justify">The assessment and monitoring must therefore include criteria that would evaluate these organ systems:</p>
<ol type="i"> <strong> </strong>
<li><strong>Lungs:</strong></li>
<strong> </strong>
<p align="justify">Monitor for sudden increases in respiratory <span style="text-decoration: underline;">rate and depth</span>, referred breath sounds and increased effort of respiration. Always remember that very anaemic <em>Babesia</em> infected dogs always have profound blood gas and acid-base disturbances, which should resolve with blood transfusion. If respiratory signs worsen or improve only to suddenly deteriorate again following transfusion, consider ARDS or pulmonary thromboembolism. Increases in rate and depth are signs on an early decrease in pulmonary compliance due to fluid accumulation in the interstitium. By the time rales are auscultated the fluid accumulation is severe the alveoli are flooded, which may be a very poor prognostic sign. Radiographs, although helpful in confirming pathology do not take the place of a careful clinical evaluation as clinical changes will precede radiographic changes.</p>
<p align="justify">The initial monitoring plan of a sick <em>Babesia</em> patient should include frequent (hourly) assessment of the respiratory rate for at least the first 6 hours. This parameter is a simple yet sensitive indicator of decreased pulmonary function.</p>
<strong> </strong>
<li><strong>Kidneys:</strong></li>
<strong> </strong>
<p align="justify">Monitor for <span style="text-decoration: underline;">urine production</span>, especially in haemoconcentrated babesiosis cases which very frequently present with ARF. Oliguria or anuria will <span style="text-decoration: underline;">precede </span>the development of azotaemia (increases in urea and creatinine). Note that haemolysis will cause an increase in urea without a linear increase in creatinine. As such <span style="text-decoration: underline;">urea used alone is a poor indicator of renal function</span> in this scenario and should always be used with creatinine or creatinine should be used alone.</p>
<strong><span style="text-decoration: underline;"> </span></strong>
<li><strong><span style="text-decoration: underline;">Secondary/acquired IMHA:</span></strong></li>
<strong><span style="text-decoration: underline;"> </span></strong>
<p align="justify">The majority of clinically ill babesiosis infected dogs are Coombs’ positive and it is estimated that about 20% of cases seen at Outpatients section of the Onderstepoort Veterinary Academic Hospital are ISA positive at the time of <em>Babesia</em> diagnosis. The decision on how to proceed with these cases is based on the PCV at the time of diagnosis, ISA positivity, the colour of the serum, and the general clinical condition of the animal Many of these patients are ISA negative within 24 – 48 hours and thus do not require a long tapering course of prednisilone as eradication of the parasite has removed the trigger or the initial test was a false positive.</p>
<p align="justify">Occasionally a case can develop into a severe and clinically important secondary IMHA where auto-antibodies have developed against normal erythrocyte membrane antigens. These patients are challenging to manage and require aggressive therapy often with multiple transfusions and strong immunosuppressive therapy of several months duration.</p>
<li>Follow-up evaluation</li>
</ol>
<p align="justify">It is important to request a re-evaluation of the dog the day following initial therapy. Uncomplicated cases will show a distinct improvement in habitus and clinical signs, although the PCV may still be quite low or even the same as the previous day. The parasitized cells are removed from circulation and the PCV may fall between 1-7% six hours after injecting of the babesiacidal agent. This percentage will obviously be affected by the regenerative capacity of the patient and the initial parasite density.</p>
<p align="justify">The monitoring of a patient with haemolytic disease /true IMHA involves the following basic in-house laboratory tests:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A repeat <strong>blood smear</strong> evaluation is essential to evaluate for regeneration and spherocytosis.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ensure that the <strong>ISA</strong> test has been performed accurately.<strong> </strong>ISA must be evaluated microscopically. If the patient is positive at a 1:6 dilution with saline, increase the ration to a 1:20. A true ISA will still be positive whereas strong rouleaux will become negative.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Determine if the<strong> PCV </strong>is stable, decreasing or increasing. This parameter must be interpreted together with the identification of regeneration on the blood smear. IMHA cases are usually highly regenerative. Good regeneration with a stable PCV indicates ongoing erythrocyte destruction. Concomitant disease or chronic inflammation may decrease the regenerative capacity.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Evaluate <strong>serum colour </strong>for haemolysis</td>
</tr>
</tbody>
</table>
<p align="justify">A typical regimen for a mild, babesiosis induced IMHA is a tapering dose of 2mg/kg decreasing to 0.5 mg/kg over 7 days.</p>
<p><strong>
<p align="justify">B. Primary IMHA</p>
</strong></p>
<p align="justify">The diagnosis of primary IMHA is challenging as it requires the <span style="text-decoration: underline;">exclusion</span> of all possible secondary causes, which are numerous.</p>
<p align="justify">To simplify matters an abridged version of causes follows.</p>
<p align="justify">Infectious: – ensure that the patient has been thoroughly examined for any chronic infections: endocarditis, osteomyelitis, discospondylitis, urinary tract infections, prostatitis, pyometra, dirofilaria, ehrlichia</p>
<p align="justify">Drugs: - many medications are capable inducing IMHA. Vaccinations, especially rabies are probable causes if given less than 3-4 weeks previously. Potentiated sulpha drugs are major inducers of auto-immune reactions and may cause immune mediated thrombocytopaenia, IMHA, immune mediated polyarthritis and keratoconjunctivitis sicca (KCS). Cephalosporins and penicillins are also predisposed.</p>
<p align="justify">Neoplastic : Neoplastic cells may express non self antigens on their cell surfaces and as such may induce a variety on immune mediated conditions e.g. Thymoma induced Myaesthenia gravis.</p>
<p><strong> </strong></p>
<p align="justify">A thorough, logical and often costly clinical and diagnostic plan is required to eliminate secondary causes.</p>
<p align="justify">Primary IMHA is more resistant to therapy and will require very gradual tapering with duration of therapy up to 6 months. In large breed dogs it is often advisable to add azathioprine early in the course of therapy to allow a reduction in the prednisilone dosage and thus decrease the side effects.</p>
<p align="justify">These dosage regimens are not a hard and fast rule but will be modified according to regular patient and haematology re-evaluations. These parameters should be re-assessed after each dosage reduction of the immunosuppressive therapy and at regular 2-3 week intervals to ensure that the condition is resolving. Often the prednisilone is tapered too rapidly and the haemolysis starts up again. If no monitoring is performed the animal will only present when the PCV is so low that it is once again causing clinical signs.</p>
<p><strong></strong></p>
<table border="1" cellspacing="1" cellpadding="7" width="649">
<tbody>
<tr>
<td colspan="4" valign="top"><strong> </strong>
<p align="center"><strong><br /></strong></p>
<strong> </strong>
<p align="center"><strong>TABLE OF DRUGS WHICH CAN BE USED TO MANAGE IMHA ( summarized)</strong></p>
<strong> </strong>
<p align="center"><strong></strong></p>
</td>
</tr>
<tr>
<td width="18%" valign="top"><strong> </strong>
<p align="justify"><strong>Drug</strong></p>
</td>
<td width="20%" valign="top"><strong> </strong>
<p align="justify"><strong>Mechanism</strong></p>
</td>
<td width="33%" valign="top"><strong> </strong>
<p align="justify"><strong>Regimen</strong></p>
</td>
<td width="28%" valign="top"><strong> </strong>
<p align="justify"><strong>Side effects/ comments</strong></p>
<strong> </strong>
<p align="justify"><strong></strong></p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Prednisilone</p>
</td>
<td width="20%" valign="top">
<p align="center">* Blocks macrophages</p>
<p align="center">* Decreases antibody production</p>
<p align="center"> </p>
<p align="center">* 4-5 days to effect</p>
</td>
<td width="33%" valign="top">
<p align="center">2-4 mg.kg/ d is immunosuppressive</p>
<p align="center">(&gt; 20kg = 3mg/day, &lt;20kg = 4mg/kg/d … BSA effect)</p>
<p align="center">taper initially by decr. dose by 50% every 2-3 weeks until 1mg/kg/day.</p>
<p align="center">Maintain for 4 weeks, then decrease to 0.5mg/kgoid for 4w then 0,5mg/kg alt days for 4-8 weeks.</p>
</td>
<td width="28%" valign="top">
<p align="center">* Large breed dogs may develop severe muscle wasting and weakness. Advise combination with azathioprine to allow dose reduction ASAP.</p>
<p align="center">* Small breeds show more typical cushingoid side effects of weight gain and pu/pd</p>
<p align="center">* GIT ulceration (prevent with MisoprostilÒ )</p>
<p align="center"> </p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Azathioprine</p>
<p align="center">( AzapressÒ )</p>
</td>
<td width="20%" valign="top">
<p align="center">* Suppresses T cell function</p>
<p align="center">* 2 weeks to peak effect</p>
</td>
<td width="33%" valign="top">
<p align="center">Initiating dose of 1-2 mg/kg / day then maintenance at 1 -2 mg/kg every alternate day</p>
<p align="center">( often alternating with prednisilone)</p>
<p align="center"> </p>
</td>
<td width="28%" valign="top">
<p align="center">* Contraindicated in cats</p>
<p align="center">* May cause pancreatitis and bone marrow suppression</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Cyclophosphamide</p>
<p align="center">(EndoxanÒ )</p>
</td>
<td width="20%" valign="top">
<p align="center">* Anti-neoplastic agent</p>
<p align="center">* Antibody and lymphocyte suppression</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">50mg/m<sup>2</sup> first 4 days of each week for maximum of 4-6 weeks.</p>
<p align="center"> </p>
<p align="center">Not recommended by the author</p>
</td>
<td width="28%" valign="top">
<p align="center">* severe bone marrow suppression</p>
<p align="center">* haemorrhagic sterile cystitis</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">HIVGG</p>
<p align="center">(Human Intravenous Gamma globulin)</p>
</td>
<td width="20%" valign="top">
<p align="center">* Saturates Macrophage Fc receptors.</p>
<p align="center">* Immediate effect</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">Indicated for erythrophagocytic IMHA.</p>
<p align="center">0.5 – 1.5 g/kg iv over 4-6 hours</p>
<p align="center"> </p>
</td>
<td width="28%" valign="top">
<p align="center">* Very Expensive</p>
<p align="center">* Bridging therapy</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Cyclosporin</p>
<p align="center"> </p>
</td>
<td width="20%" valign="top">
<p align="center">* Inhibits amplification of immune reaction</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">5 – 15 mg/kg / day</p>
<p align="center">serum levels &gt; 200ng/ml</p>
</td>
<td width="28%" valign="top">
<p align="center">* Expensive</p>
<p align="center">* Bridging therapy</p>
</td>
</tr>
<tr>
<td width="18%" valign="top">
<p align="center">Danazol</p>
</td>
<td width="20%" valign="top">
<p align="center">* Decreases RBC fragility</p>
<p align="center"> </p>
</td>
<td width="33%" valign="top">
<p align="center">5mg/kg tid</p>
</td>
<td width="28%" valign="top">
<p align="center">* For chronic management</p>
</td>
</tr>
</tbody>
</table>
<p>References:</p>
<ol>
<li> <ol>
<li>Jacobson LS, Reyers F et al. Changes in haematocrit after treatment of uncomplicated canine babesiosis: a comparison between diminazine and trypan blue, and an evaluation of the influence of parasitaemia. <em>Journal of the South African Veterinary Association </em>1996 vol. 67 (2) pp 95 – 105</li>
<li>Grundy SA, Barton C. Influence of drug treatment on survival of dogs with immune mediated haemolytic anaemia: 88 cases (1989 – 1999) <em>Journal of the American Veterinary Medical Assosciation. </em>2001 vol. 218 (4)543 – 545</li>
<li>Kellerman DL, Bruyette DS. Intravenous Human Immunoglobulin for the Treatment of Immune-Mediated Hemolytic Anemia in 13 Dogs. <em>Journal of Veterinary Internal Medicine </em>1997 vol 11 (6) pp 327 – 332</li>
<li>Reimer ME, Troy GC, Warnick LD .Immune –Mediated Hemolytic Anemia: 70 cases (1988 – 1996<em>). Journal of the American Animal Hospital Association</em> 1999 Vol. 35 pp 384 – 391</li>
<li>Slappendal R.J. Interpretation of tests for immune mediated blood diseases. In <em>Kirks Current Veterinary Therapeutics</em> X (Eds) Kirk and Bonagura. pg: 498 – 50.</li>
<li>Stewart A.F., Feldman B.F. Immune mediated hemolytic anemia. Part I. Clinical Entity, Diagnosis, and Treatment Theory. <em>Compendium on Continuing Education for the Practicing Veterinarian</em> 1993 Vol. 15 (11) pp 1479 – 1993</li>
<li>Stewart A.F., Feldman B.F. Immune mediated hemolytic anemia. Part II. An Overview. <em>Compendium on Continuing Education for the Practicing Veterinarian </em>1993 Vol15 (3) pp 372 – 381</li>
<li>Vaughn Scott T, Jacobson L.S. et al Systemic Inflammatory Response syndrome and multiple-organ damage /dysfunction in complicated canine babesiosis. <em>Journal of the South African Veterinary Association </em>2001 vol 72 (3) pp 158 – 162</li>
</ol></li>
</ol></div>Guidelines - What does it mean to "stabilise" a critically ill small animal patient before anaesthetic induction?2009-09-02T11:12:13+00:002009-09-02T11:12:13+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/242-guidelines-what-does-it-mean-to-qstabiliseq-a-critically-ill-small-animal-patient-before-anaesthetic-inductionAdministratorwebmaster@savc.org.za<div class="feed-description"><p><strong>
<p align="justify">What does it mean to "stabilise" a critically ill small animal patient before anaesthetic induction?</p>
</strong></p>
<p align="justify">A L Leisewitz, F Kettner, K Joubert , A Zambelli, N Keller, E Scheepers, M Bohm.</p>
<p align="justify">Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort.</p>
<ol>
<li>What is an ‘unstable’ patient?</li>
</ol>
<p>A patient that presents in shock or one that is unable to adequately compensate physiologically during an intervention such as anaesthesia. Shock can be defined and suspected under the following circumstances:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A dog or cat that is weak or collapsed. A depressed level of consciousness or sudden decrease in mentation are indicators of decompensation. These changes should be viewed in light of the nature of the trauma the patient has experienced (for example head trauma), or the possibility of a toxicity. Patients that have a sudden change in consciousness should be re-evaluated;</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Shock typically causes a low rectal temperature (although temperature may be high in cases of sepsis or blood stream infections) and cold peripheral extremities;</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Shock is associated with a tachycardia (although cats may have normal pulse and be in shock) or bradycardic; Tachycardia may be the result of pain in trauma patients and if the heart rate fails to decrease after an appropriate dose of an analgesic, hypovolaemia should be suspected. Patients that are tachycardic or normocardic where there is a suspicion of hypovolaemia or shock should be challenged with a fluid bolus equal to about 10% of their blood volume (approximately 10 ml/kg in dogs) given over 5-15 minutes. Changes in heart rate and blood pressure (the quality of the pulse) should be assessed. Before treating a patient that is bradycardic with atropine the following contraindications should be excluded: hypoxia, hypothermia and electrolyte imbalances (increased blood K<sup>+</sup>).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Capillary refill time is typically prolonged in established shock but in hyperdynamic shock and early septic shock this may not be the case (mucous membranes are also usually pale but may be injected in hyperdynamic or septic shock);</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">An attempt to feel the quality of the femoral or other peripheral arterial pulse should be made. If a peripheral pulse cannot be felt, arterial blood pressure is below 60 mmHg and this requires urgent attention.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Respiratory rate and pattern can be good indicator of patient stability. A fast respiratory rate with shallow breathing and an irregular pattern are indicators of an unstable patient. Rapid deep breathing cannot be sustained over a prolonged period and should warn about possible respiratory muscle failure.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Urine production is the ‘poor-man’s’ blood pressure machine. Measuring urine production is cheap and easy, requiring minimal invasiveness and time. It provides an objective means of evaluating blood pressure over time, rather than an instantaneous assessment at the time of the examination. Production in excess of 0.5ml/kg/hour usually indicates normal blood pressure</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Blood glucose is often abnormal in unstable patients. It may both be high (as in some cases of septic shock and head trauma) and low (e.g. canine babesiosis)</td>
</tr>
</tbody>
</table>
<p align="justify">Patients in compensated shock are more problematic as they may suddenly decompensate or may become unstable following the administration of anaesthesia.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A patient that has lost a large quantity of blood and is anaemic may be unable to maintain oxygen delivery under anaesthesia. Patients with long bone fractures can loose significant quantities of blood into the haematoma surrounding the fracture. Haematocrit is a poor indicator of acute blood loss. In these cases cardiovascular signs maybe a better indicator of the need for blood pressure support.</td>
</tr>
</tbody>
</table>
<p align="justify">Patients showing severe dyspnoea should be regarded as unstable even if not in shock.</p>
<ol> <strong><span style="text-decoration: underline;"> </span></strong>
<li><strong><span style="text-decoration: underline;">What does it mean to ‘stabilise’ a patient (what are the therapeutic end-points?)?</span></strong></li>
<strong><span style="text-decoration: underline;"> </span></strong> </ol>
<p><strong><span style="text-decoration: underline;"> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Stabilisation is the treatment that is given in the interim period from admission until the primary problem can be, or is, addressed. The benefit of stabilisation should always be greater than the cost of delaying primary treatment.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">To restore arterial blood pressure and tissue oxygenation to as close to normal as possible. Blood pressure and tissue oxygenation cannot be directly assessed in most general practice environments in South Africa so we are forced to use markers of these indices. These have been listed above in question 1.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">These markers should be showing a consistent tendency towards normalisation. It is important to appreciate that <em>trends</em> in the observations are very important and the establishment of trends requires frequent monitoring during the post event period. In critically ill animals it is probably unrealistic to expect a complete normalisation of these measurements and observations. This is a very important point to remember. There is no way that leaving a shocked patient in a cage overnight on a drip only to be re-examined the next morning for the first time can be seen as ethical practice.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>What are the general therapeutic interventions used in stabilising a patient before any anaesthetic can be administered?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Intravenous fluid and colloid infusion (at shock doses) to expand circulating volume and thus increase blood pressure.</td>
</tr>
</tbody>
</table>
<p align="justify">Caution in fluid administration must be exercised in patients with brain trauma, anuric renal failure, hypoproteinemia, lung oedema and lung contusions as fluid overload may be more rapidly lethal in these cases. Fluid overloading is more rapidly a problem in cats and more caution must be exercised when fluid loading this species.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">
<p align="justify">The correction of any abnormal life-threatening biochemical disorders (such as severe hypoprotienaemia, hyperkalaemia, hypoglycaemia, hyper or hypoclacaemia or ketoacidosis), the correction of anaemia due to haemolysis (to a haematocrit of at least 20%) or whole blood loss (until blood pressure is above 70 mmHg – the approximate level at which femoral pulses can be palpated).</p>
</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ensure adequate urine production.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The correction of any life threatening respiratory abnormality such as serious thoracic effusion or flail chest. This should be accompanied by the administration of nasal oxygen.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The needle drainage of acute pericardial effusion that threatens cardiac output to the point of causing cardiogenic shock.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The needle trocharisation of life threatening gastric gas distension in gastric dilatation volvulus syndrome (GDV).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The correction (or at least an attempt to) of life threatening cardiac arrhythmias.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The arrest of any significant bleeding that can be stopped without surgical intervention.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The correction of acute bleeding tendencies due to clotting factor or platelet deficiencies to the point that spontaneous haemorrhage has subsided.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The supplementation of oxygen initially has few contraindications and can be safely used in most patients. Ventilation should be assessed for adequacy in terms of respiratory rate and tidal volume. Patients with slow respiratory rates (&lt; 8 – 10) and low tidal volume should be ventilated to maintain adequate oxygenation with 100% oxygen until a diagnosis is made. Emergencies where ventilation is a consideration are usually caused by diseases of the neuromuscular junction, brain stem trauma or pleural space occupying lesions.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If blood pressure is still not adequately supported once adequate volume resuscitation has occurred, administer positive inotropes (dobutamine constant rate infusion) or vasoconstrictors (dopamine constant rate infusion).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Peritoneal lavage to removed purulent septic material should exploratory celiotomy not be possible at that stage (by mean of local anaesthesia and a keyhole incision into abdomen through which a Foley’s catheter can be passed to lavage the abdomen).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Pain should be addressed. Patients will often remain unstable if left in severe pain.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Severely hypothermic patients must have this need appropriately addressed if they are to be stabilised.</td>
</tr>
</tbody>
</table>
<ol> <strong><span style="text-decoration: underline;"> </span></strong>
<li><strong><span style="text-decoration: underline;">How long should stabilisation take?</span></strong></li>
<strong><span style="text-decoration: underline;"> </span></strong> </ol>
<p><strong><span style="text-decoration: underline;"> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">As fast as possible. Volume resuscitation in hypovolaemic shock should not take longer than 30-60 minutes.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">This said the time required to stabilise a patient can be highly variable and will depend on the underlying condition. Some patients never reach sufficient stability to allow for interventions under anaesthetic. It must however be stressed that continuous and close monitoring of unstable patients is absolutely essential if life saving interventions that require a general anaesthetic are necessary. Only close and frequent monitoring will allow a well-timed decision as to when the best time to administer an anaesthetic might be.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">It is important to remember that stabilisation should be achieved in the shortest safe period and once a patient is showing trends towards stabilisation urgent procedures under anaesthetic should be performed. In other words medical interventions may only provide a short window of opportunity during which more permanently stabilising procedures that require general anaesthesia (GA) can be applied. Delaying invasive interventions unnecessarily will cost a life in many situations.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Generally speaking stabilization should not take longer than a few hours. In most cases it should be achieved within the first hour or two after presentation.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>Under what emergency situations can one not afford to wait before administering an anaesthetic?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If a patient needs such an urgent intervention to save its life (like an obstructed trachea in a dog that you cannot relieve without an anaesthetic such as a puff adder bite that needs an emergency tracheostomy or a trauma patient that will die without an immediate insertion of an ET tube or a bulldog with heat stroke that has such bad laryngeal oedema or collapse that it is cyanotic and deteriorating in front of your eyes).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If a patient is in life-threatening status epilepticus (such as with strychnine poisoning or following cranial trauma).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A dog or cat with a flail chest or pleural effusion that will not tolerate a conscious needle drainage or drain insertion under local anaesthetic for stabilisation.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A patient with rupture of an organ that is haemorrhaging causing haemothorax or haeomoperitoneum (such as a ruptured liver or spleen). These patients will require emergency transfusion whilst surgical intervention to stop the bleeding occurs.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A patient in a state of collapse following a neurotoxic snakebite that requires mechanical ventilation.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Patients with a ruptured gastro-intestinal tract, strangulation or volvulus lesion should undergo surgical correction as soon as possible. The longer contamination of the peritoneal cavity is present the poorer the outcome is.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>When should primary intervention to correct the underlying problem be initiated?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Intervention to correct the underlying primary problem should be performed when the risk of delaying further treatment is greater than the benefit of continuing stabilisation. Complete normalisation may not yet have been achieved.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">When further stabilisation is no longer possible due to ongoing deterioration of the patient’s condition.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">When the patient is stable enough (i.e. not yet normalised) to undergo intervention to correct the primary problem.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">As an example, a patient with septic peritonitis may benefit from surgical treatment before stabilisation to "normal" levels, as it is quite likely that this cannot be achieved before the abdomen has been lavaged.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>Which emergency situations usually need stabilisation before anaesthetics can be administered?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Cats with obstructive uropathy that are hyperkalaemic. These cats should have their bladders needle drained and the hyperkalaemia should be resolved before catheterisation under general anaesthetic.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Patients with clinically significant pulmonary contusion (usually following road traffic accidents).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Dogs with GDV should be trocharised and urgently fluid loaded at the same time before an anaesthetic is given. Some of these patients can be stomach tubed by mouth without anaesthetic but most will require at least a short anaesthetic for this. If these dogs are in shock it is my/our opinion that the stomach should be deflated and the vascular compartment fluid and colloid loaded before surgical anaesthetic is administered.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">All patients in shock as a result of trauma that is not resulting in immediate life threatening danger (such as listed above). Fight wounds and dogs involved in motor vehicle accidents are common examples. Adequate resuscitation is normally required before radiographic examinations, wound care or complete assessments can be made. It is important to remember however that a patient that has been injured may only destabilise after admission and as such trauma patients should be closely monitored.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">All dogs with a blood loss anaemia (and MAP below 70 mmHg) or haemolytic anaemia (with haematocrits below 20%)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Pyometra/septic peritonitis cases may need stabilisation although most cases are sufficiently stabile to intervene immediately. The general rule of thumb in any septic patient is to surgically drain or remove the source of sepsis without any or the minimum of delay. Any stabilisation without doing this can be expected to be short lived.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Cases that are clinically dehydrated should be rehydrated in the shortest possible time before urgent anaesthetics are administered.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Cases in low output cardiac failure that is not stable on treatment.</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">8. <span style="text-decoration: underline;">Anaesthesia</span></p>
</strong></p>
<p align="justify">The appropriate use of anaesthetic agents is dependent on the clinical situation of the patient and a thorough knowledge of the clinical pharmacology of drugs used. There is little evidence to support the use of specific drugs and their influence on outcome is negligible. The most important determinate of outcome is the treatment and maintenance of stable cardiovascular and respiratory function (ensuring an adequate oxygen delivery to all cells in the body).</p>
<p align="justify">Essentially patients can be classified into three categories:</p>
<ol>
<li> <ol>
<li> <ol>
<li> <ol>
<li> <ol>
<li>those who are stable may receive a standard induction or slightly reduced induction dose;</li>
<li>those who are unstable should have the anaesthetic slowly titrated to effect;</li>
<li>those who are moribund or near death where minimal anaesthesia should be used.</li>
</ol></li>
</ol></li>
</ol></li>
</ol></li>
</ol>
<p align="justify">General principles to be remembered when anaesthetising compromised patients include the optimisation of tissue perfusion and oxygen delivery to all organ systems while achieving analgesia, muscle relaxation and unconsciousness.</p>
<p><strong>
<p align="justify">A. Pre-anaesthetic Management</p>
</strong></p>
<p align="justify">In certain cases prompt surgical treatment is life saving (uncontrolled haemorrhage, perforated intestines, ruptured pyometra or uterus, etc) but generally the accompanying shock is more dangerous than the initial trauma. In these cases the treatment of shock is the priority before surgical correction is attempted.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Oxygen supplementation</td>
</tr>
</tbody>
</table>
<p align="justify">This is almost always indicated and can be achieved with a facemask, nasal catheter, endotracheal tube or oxygen chamber. The use of an oxygen chamber is not ideal, as it does not allow access to the patient. Oxygen supplementation is especially important in cases with respiratory and cardiac compromise. In anaemic patients correcting haematocrit is more important than oxygen therapy. Remember not to stress animals attempting to administer oxygen. Free flow oxygen passed the face may be the best way of administration in cases that are overly anxious.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Analgesics and sedatives and premedications</td>
</tr>
</tbody>
</table>
<p align="justify">Useful premedications include morphine and diazepam and these are usually indicated. Acetylpromazine and alpha-2 agonists are generally contraindicated. These are required for the management of pain, fear and apprehension. Analgesia should be applied as soon as possible and be maintained post trauma or post-surgery.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Anticholinergics</td>
</tr>
</tbody>
</table>
<p align="justify">These are not routinely used in trauma patients as they increase myocardial oxygen demand and reduce the threshold for arrhythmias. Atropine or glycopyrrolate may be used when vagal influence affect cardiac function or secretions need to be controlled. Trauma patients are often not starved and this increases the incidence of aspiration. Methods to reduce aspiration include position of the head lower than the abdomen, immediate intubation with a cuffed endotracheal tube and suctioning if reflux occurs.</p>
<p><strong>
<p align="justify">B. Induction Agents</p>
</strong></p>
<p align="justify">It is always best to remember that the drug with which you have the most personal experience is most likely to be the safest drug in your hands. Always remember that anaesthetic drugs administered to a patient in shock in the same way as they would be used in a healthy patient will aggravate shock. This is because these drugs have potent respiratory and cardiovascular depressive effects that will exacerbate the state of shock.</p>
<p align="justify">Intravenous agents:</p>
<p align="justify">Barbiturates are known to decrease myocardial contractility, depress baroreceptor reflexes, vasodilatation, decreases venous return and depress respiration. They are poor analgesics and have no muscle relaxation. Barbiturates are arrhythmogenic when given rapidly intravenously. <strong>Propofol</strong> has less of myocardial depressant effect and fewer arrhythmias than <strong>thiopentone.</strong> The degree of myocardial depression is a function of dose and rate of injection. Barbiturates are highly protein bound and the acid-base balance; albumin content and concurrent drug administration influence their pharmacokinetics. Critically ill patients are often acidotic and hypoproteinemic and thus require lower anaesthetic doses.</p>
<p align="justify">Propofol causes similar haemodynamic effects as thiopentone and cannot be recommended over thiopentone unless the patient is cardiovascularly stable.</p>
<p align="justify">Both these agents should be given very slowly intravenously to effect to achieve a plane of anaesthesia just sufficient for intubation. Rapid administration of these agents in states of myocardial hypoxia can be fatal and it is therefore essential to supplement oxygen and ensure adequate blood pressure before induction. Propofol has a greater tendency than thiopentone to cause induction apnoea, especially if given too fast. This may prove fatal in hypoxaemic animals.</p>
<p align="justify">Ketamine is one of the few drugs with indirect cardiovascular stimulatory properties. It raises blood pressure secondary to a sympathetic increase in heart rate and cardiac output. It is contraindicated in any patient with myocardial disease or in a patient in maximal sympathetic stimulation (which is often the case in severe trauma or haemorrhagic shock). Ketamine is a poor muscle relaxant and spontaneous movement is possible. Ketamine increases intracranial pressure and is contra-indicated in cranial trauma. Benzodiazepines may be used with ketamine to enhance muscle relaxation.</p>
<p><strong>
<p align="justify">Opioid induction</p>
</strong></p>
<p align="justify">This mode of induction is the preferred method for induction in compromised patients but needs to be used with caution and a complete description of the use of this modality is beyond the scope of this short review. Opioids are most commonly combined with benzodiazepines and the opioid drugs most commonly used include fentanyl, morphine and midazolam. Mixed agonist-antagonists include buprenorphine and are not preferred due to their ceiling effects and an inability to titrate the analgesia.</p>
<p align="justify">Because opioids (especially fentanyl) result in respiratory depression pre-oxygenation is advisable. Bradycardia may occur and is treatable with anticholinergics and in refractory cases adrenaline may be used. Morphine is associated with a dose dependent histamine release and may result in hypotension. Adequate fluid loading can minimise this negative effect and should not be a reason for withholding morphine administration. Opioid combinations (eg fentanyl and morphine) have been used successfully. Opioid induction (with for example diazepam and fentanyl) is slower than conventional methods and if rapid intubation is required it cannot be recommended. Opioids are administered to the point where tracheal intubation is possible.</p>
<p align="justify">Inhalation agents</p>
<p align="justify">These are as hypotensive as barbiturates and are only safer because the period of time from drug application to surgical anaesthesia is longer thus allowing for a longer period of time for the body to establish homeostasis for their depressant effects on blood pressure. Halothane and isoflurane both cause a dose dependent cardiovascular depression. Isoflurane is the least depressant at equipotent minimum alveolar concentration values. Isoflurane is also less arrhythmogenic and causes a quicker induction than halothane. If a traumatised patient is alert it is likely to struggle with gas induction. This struggle may result in increased circulating catecholamines which may result in arrhythmias (especially with halothane) as halothane sensitises the myocard to adrenaline. Inhalation agents have no muscle relaxing or analgesic properties.</p>
<p align="justify">Some dogs in severe shock require no anaesthesia and only some analgesia in order for surgery to be performed. A less depressant form of analgesia using a local anaesthetic block should be considered. Epidural anaesthesia can be useful tool for abdominal or hind limb procedures. Patients should be fluid loaded as epidural anaesthesia can result in vasodilatation. The lowest possible dose of anaesthetic should be used and all intravenous agents should be titrated to effect.</p>
<p align="justify">Maintenance of anaesthesia.</p>
<p align="justify">Some patients may require mechanical ventilation. The fact that a patient is breathing does not necessarily mean it is adequately ventilating. Remember also that an anaemic, pale patient may not show cyanosis. Close monitoring of the measures of blood pressure, perfusion and tissue oxygenation must be maintained constantly throughout the period of anaesthesia. In addition to close physical assessment of these measures of the patient’s condition, additional monitoring that is very useful includes ECG, pulse oximetery, blood pressure (invasive arterial and or central venous pressure), and capnography. Haemodynamic stability is maintained with fluids, ionotropic agents (dobutamine constant rate infusion), vasoconstrictors (dopamine or adrenalin constant rate infusion) and colloids. Direct arterial blood pressure measurement and central venous pressure can be used to monitor haemodynamic stability. Urinary output is easily monitored with a catheter and is an important indicator of renal perfusion and fluid balance.</p>
<p align="justify">A combination of inhalation agents, opioids, benzodiazepines or ketamine can be given for maintenance.</p>
<p align="justify">Hypothermia kills and patients should be warmed or the body temperature maintained using hot warm bottles, warm water blankets, heating lamps or warm air heating devices during all anaesthetic procedures and post operative care should pay special attention to this aspect.</p>
<p><strong><span style="text-decoration: underline;">
<p align="justify">Useful references include (but are not limited to) the following texts:</p>
</span></strong></p>
<p style="line-height: 100%; ">Manual of Canine and Feline Emergency and Critical Care</p>
<p style="line-height: 100%; " align="justify">Ed: L King, R Hammond.</p>
<p style="line-height: 100%; " align="justify">Published by BSAVA, United Kingdom</p>
<p style="line-height: 100%; " align="justify">1999</p>
<p style="line-height: 100%; " align="justify">ISBN 0 905214 40 4</p>
<p style="line-height: 100%; ">Emergency Medicine in Small Animal Practice</p>
<p style="line-height: 100%; " align="justify">The Compendium Collection</p>
<p style="line-height: 100%; " align="justify">Published by Veterinary Learning Systems, Trenton, New Jersey.</p>
<p style="line-height: 100%; " align="justify">1997</p>
<p style="line-height: 100%; " align="justify">ISBN 1 884254 24 1</p>
<p style="line-height: 100%; ">Small Animal Emergency and Critical Care. A Manual for the Veterinary Technologist.</p>
<p style="line-height: 100%; ">A M Battaglia</p>
<p style="line-height: 100%; " align="justify">Published by WB Saunders Co.</p>
<p style="line-height: 100%; " align="justify">2000</p>
<p style="line-height: 100%; " align="justify">ISBN 0 7216 7773 8</p>
<p style="line-height: 100%; " align="justify">Emergency Procedures for the Small Animal Veterinarian.</p>
<p style="line-height: 100%; " align="justify">SJ Plunkett</p>
<p style="line-height: 100%; " align="justify">WB Saunders, Philadelphia</p>
<p style="line-height: 100%; " align="justify">1993</p>
<p style="line-height: 100%; " align="justify">ISBN 0 7216 6781 3</p>
<p style="line-height: 100%; " align="justify">Self Assessment Colour Review of Small Animal Emergency and Critical Care Medicine.</p>
<p style="line-height: 100%; " align="justify">R Kirbey</p>
<p style="line-height: 100%; " align="justify">Mason Publishing Ltd, London, UK.</p>
<p style="line-height: 100%; " align="justify">1998</p>
<p style="line-height: 100%; " align="justify">ISBN 1 874545 65 6</p>
<p style="line-height: 100%; ">Fluid Therapy in Small Animal Practice. 2<sup>nd</sup> Edition.</p>
<p style="line-height: 100%; " align="justify">Editor: SP DiBartola</p>
<p style="line-height: 100%; " align="justify">WB Saunders Co. Philadelphia</p>
<p style="line-height: 100%; " align="justify">2000</p>
<p style="line-height: 100%; " align="justify">ISBN 0 7216 7739 8.</p>
<p><strong>
<p align="left">Some useful drugs and doses are tabulated below.</p>
</strong></p>
<table border="1" cellspacing="1" width="740" align="left">
<tbody>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"></td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>NAME</strong></p>
</td>
<td width="32%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>DOSAGE</strong></p>
</td>
<td width="15%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>ROUTE</strong></p>
</td>
<td width="14%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>STRENGTH</strong></p>
</td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"><strong> </strong>
<p align="center"><strong>PREMEDICATION</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>ATROPINE SULPHATE</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>0.02 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>0.5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>(ATORPINE)</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>0.04 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">s/c</p>
</td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>MIDAZOLAM</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>0.3 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/m or i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>DIAZEPAM</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>0.2 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"></td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"><strong> </strong>
<p align="center"><strong>INDUCTION</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>THIOPENTONE SODIUM</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>10 mg/kg (with premed)</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>25 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom">
<p>15 mg/kg (without premed)</p>
</td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>PROPOFOL</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>4 - 6 mg/kg (with premed)</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>10 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>6-8 mg/kg (without premed)</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>KETAMINE</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>5 - 10 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>100 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom">
<p>10 - 20 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/m</p>
</td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>FENTANYL</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>40 microgram/kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/m or i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>0.2 mg/ml</p>
</td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"><strong> </strong>
<p><strong>OTHER</strong></p>
</td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>ADRENALINE</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>1 ml/10 kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">1/1000</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>ATROPINE</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>1 ml/10 kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p align="center">0.5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>LIGNOCAINE</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>1 ml/10 kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">2%</p>
</td>
</tr>
<tr>
<td colspan="4" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"></td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"><strong> </strong>
<p align="center"><strong>ANALGESICS</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>MORPHINE SULPHATE</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0">
<p>0.2-0.4 mg/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0">
<p>s/c or i/v</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0">
<p>10 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>(MORPHINE)</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>FENTANYL</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0">
<p>10 – 20 microgram/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0">
<p>i/m or i/v</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0">
<p>0.2 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="top">
<p>BUPRENORPHINE</p>
</td>
<td width="32%" height="18" valign="top">
<p>0.02 mg/kg</p>
</td>
<td width="15%" height="18" valign="top">
<p>i/m</p>
</td>
<td width="14%" height="18" valign="top">
<p>0.3 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top"></td>
<td width="32%" height="18" valign="top"></td>
<td width="15%" height="18" valign="top"></td>
<td width="14%" height="18" valign="top"></td>
</tr>
<tr>
<td colspan="4" height="18" valign="top"><strong> </strong>
<p align="center"><strong>EPIDURALS</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>MORPHINE SULPHATE</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0">
<p>0.1 mg/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0">
<p>EPIDURAL</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0">
<p>10 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>(MORPHINE)</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#ffffff">
<p>ROPIVACAINE</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#ffffff">
<p>1 mg/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#ffffff">
<p>EPIDURAL</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#ffffff">
<p>7.5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#ffffff"></td>
<td width="32%" height="18" valign="top" bgcolor="#ffffff"></td>
<td width="15%" height="18" valign="top" bgcolor="#ffffff"></td>
<td width="14%" height="18" valign="top" bgcolor="#ffffff"></td>
</tr>
</tbody>
</table>
<p align="left"><em>(Published Newsletter 38, November 2004)</em></p></div><div class="feed-description"><p><strong>
<p align="justify">What does it mean to "stabilise" a critically ill small animal patient before anaesthetic induction?</p>
</strong></p>
<p align="justify">A L Leisewitz, F Kettner, K Joubert , A Zambelli, N Keller, E Scheepers, M Bohm.</p>
<p align="justify">Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort.</p>
<ol>
<li>What is an ‘unstable’ patient?</li>
</ol>
<p>A patient that presents in shock or one that is unable to adequately compensate physiologically during an intervention such as anaesthesia. Shock can be defined and suspected under the following circumstances:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A dog or cat that is weak or collapsed. A depressed level of consciousness or sudden decrease in mentation are indicators of decompensation. These changes should be viewed in light of the nature of the trauma the patient has experienced (for example head trauma), or the possibility of a toxicity. Patients that have a sudden change in consciousness should be re-evaluated;</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Shock typically causes a low rectal temperature (although temperature may be high in cases of sepsis or blood stream infections) and cold peripheral extremities;</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Shock is associated with a tachycardia (although cats may have normal pulse and be in shock) or bradycardic; Tachycardia may be the result of pain in trauma patients and if the heart rate fails to decrease after an appropriate dose of an analgesic, hypovolaemia should be suspected. Patients that are tachycardic or normocardic where there is a suspicion of hypovolaemia or shock should be challenged with a fluid bolus equal to about 10% of their blood volume (approximately 10 ml/kg in dogs) given over 5-15 minutes. Changes in heart rate and blood pressure (the quality of the pulse) should be assessed. Before treating a patient that is bradycardic with atropine the following contraindications should be excluded: hypoxia, hypothermia and electrolyte imbalances (increased blood K<sup>+</sup>).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Capillary refill time is typically prolonged in established shock but in hyperdynamic shock and early septic shock this may not be the case (mucous membranes are also usually pale but may be injected in hyperdynamic or septic shock);</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">An attempt to feel the quality of the femoral or other peripheral arterial pulse should be made. If a peripheral pulse cannot be felt, arterial blood pressure is below 60 mmHg and this requires urgent attention.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Respiratory rate and pattern can be good indicator of patient stability. A fast respiratory rate with shallow breathing and an irregular pattern are indicators of an unstable patient. Rapid deep breathing cannot be sustained over a prolonged period and should warn about possible respiratory muscle failure.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Urine production is the ‘poor-man’s’ blood pressure machine. Measuring urine production is cheap and easy, requiring minimal invasiveness and time. It provides an objective means of evaluating blood pressure over time, rather than an instantaneous assessment at the time of the examination. Production in excess of 0.5ml/kg/hour usually indicates normal blood pressure</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Blood glucose is often abnormal in unstable patients. It may both be high (as in some cases of septic shock and head trauma) and low (e.g. canine babesiosis)</td>
</tr>
</tbody>
</table>
<p align="justify">Patients in compensated shock are more problematic as they may suddenly decompensate or may become unstable following the administration of anaesthesia.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A patient that has lost a large quantity of blood and is anaemic may be unable to maintain oxygen delivery under anaesthesia. Patients with long bone fractures can loose significant quantities of blood into the haematoma surrounding the fracture. Haematocrit is a poor indicator of acute blood loss. In these cases cardiovascular signs maybe a better indicator of the need for blood pressure support.</td>
</tr>
</tbody>
</table>
<p align="justify">Patients showing severe dyspnoea should be regarded as unstable even if not in shock.</p>
<ol> <strong><span style="text-decoration: underline;"> </span></strong>
<li><strong><span style="text-decoration: underline;">What does it mean to ‘stabilise’ a patient (what are the therapeutic end-points?)?</span></strong></li>
<strong><span style="text-decoration: underline;"> </span></strong> </ol>
<p><strong><span style="text-decoration: underline;"> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Stabilisation is the treatment that is given in the interim period from admission until the primary problem can be, or is, addressed. The benefit of stabilisation should always be greater than the cost of delaying primary treatment.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">To restore arterial blood pressure and tissue oxygenation to as close to normal as possible. Blood pressure and tissue oxygenation cannot be directly assessed in most general practice environments in South Africa so we are forced to use markers of these indices. These have been listed above in question 1.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">These markers should be showing a consistent tendency towards normalisation. It is important to appreciate that <em>trends</em> in the observations are very important and the establishment of trends requires frequent monitoring during the post event period. In critically ill animals it is probably unrealistic to expect a complete normalisation of these measurements and observations. This is a very important point to remember. There is no way that leaving a shocked patient in a cage overnight on a drip only to be re-examined the next morning for the first time can be seen as ethical practice.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>What are the general therapeutic interventions used in stabilising a patient before any anaesthetic can be administered?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Intravenous fluid and colloid infusion (at shock doses) to expand circulating volume and thus increase blood pressure.</td>
</tr>
</tbody>
</table>
<p align="justify">Caution in fluid administration must be exercised in patients with brain trauma, anuric renal failure, hypoproteinemia, lung oedema and lung contusions as fluid overload may be more rapidly lethal in these cases. Fluid overloading is more rapidly a problem in cats and more caution must be exercised when fluid loading this species.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">
<p align="justify">The correction of any abnormal life-threatening biochemical disorders (such as severe hypoprotienaemia, hyperkalaemia, hypoglycaemia, hyper or hypoclacaemia or ketoacidosis), the correction of anaemia due to haemolysis (to a haematocrit of at least 20%) or whole blood loss (until blood pressure is above 70 mmHg – the approximate level at which femoral pulses can be palpated).</p>
</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ensure adequate urine production.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The correction of any life threatening respiratory abnormality such as serious thoracic effusion or flail chest. This should be accompanied by the administration of nasal oxygen.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The needle drainage of acute pericardial effusion that threatens cardiac output to the point of causing cardiogenic shock.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The needle trocharisation of life threatening gastric gas distension in gastric dilatation volvulus syndrome (GDV).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The correction (or at least an attempt to) of life threatening cardiac arrhythmias.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The arrest of any significant bleeding that can be stopped without surgical intervention.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The correction of acute bleeding tendencies due to clotting factor or platelet deficiencies to the point that spontaneous haemorrhage has subsided.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The supplementation of oxygen initially has few contraindications and can be safely used in most patients. Ventilation should be assessed for adequacy in terms of respiratory rate and tidal volume. Patients with slow respiratory rates (&lt; 8 – 10) and low tidal volume should be ventilated to maintain adequate oxygenation with 100% oxygen until a diagnosis is made. Emergencies where ventilation is a consideration are usually caused by diseases of the neuromuscular junction, brain stem trauma or pleural space occupying lesions.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If blood pressure is still not adequately supported once adequate volume resuscitation has occurred, administer positive inotropes (dobutamine constant rate infusion) or vasoconstrictors (dopamine constant rate infusion).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Peritoneal lavage to removed purulent septic material should exploratory celiotomy not be possible at that stage (by mean of local anaesthesia and a keyhole incision into abdomen through which a Foley’s catheter can be passed to lavage the abdomen).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Pain should be addressed. Patients will often remain unstable if left in severe pain.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Severely hypothermic patients must have this need appropriately addressed if they are to be stabilised.</td>
</tr>
</tbody>
</table>
<ol> <strong><span style="text-decoration: underline;"> </span></strong>
<li><strong><span style="text-decoration: underline;">How long should stabilisation take?</span></strong></li>
<strong><span style="text-decoration: underline;"> </span></strong> </ol>
<p><strong><span style="text-decoration: underline;"> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">As fast as possible. Volume resuscitation in hypovolaemic shock should not take longer than 30-60 minutes.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">This said the time required to stabilise a patient can be highly variable and will depend on the underlying condition. Some patients never reach sufficient stability to allow for interventions under anaesthetic. It must however be stressed that continuous and close monitoring of unstable patients is absolutely essential if life saving interventions that require a general anaesthetic are necessary. Only close and frequent monitoring will allow a well-timed decision as to when the best time to administer an anaesthetic might be.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">It is important to remember that stabilisation should be achieved in the shortest safe period and once a patient is showing trends towards stabilisation urgent procedures under anaesthetic should be performed. In other words medical interventions may only provide a short window of opportunity during which more permanently stabilising procedures that require general anaesthesia (GA) can be applied. Delaying invasive interventions unnecessarily will cost a life in many situations.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Generally speaking stabilization should not take longer than a few hours. In most cases it should be achieved within the first hour or two after presentation.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>Under what emergency situations can one not afford to wait before administering an anaesthetic?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If a patient needs such an urgent intervention to save its life (like an obstructed trachea in a dog that you cannot relieve without an anaesthetic such as a puff adder bite that needs an emergency tracheostomy or a trauma patient that will die without an immediate insertion of an ET tube or a bulldog with heat stroke that has such bad laryngeal oedema or collapse that it is cyanotic and deteriorating in front of your eyes).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If a patient is in life-threatening status epilepticus (such as with strychnine poisoning or following cranial trauma).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A dog or cat with a flail chest or pleural effusion that will not tolerate a conscious needle drainage or drain insertion under local anaesthetic for stabilisation.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A patient with rupture of an organ that is haemorrhaging causing haemothorax or haeomoperitoneum (such as a ruptured liver or spleen). These patients will require emergency transfusion whilst surgical intervention to stop the bleeding occurs.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A patient in a state of collapse following a neurotoxic snakebite that requires mechanical ventilation.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Patients with a ruptured gastro-intestinal tract, strangulation or volvulus lesion should undergo surgical correction as soon as possible. The longer contamination of the peritoneal cavity is present the poorer the outcome is.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>When should primary intervention to correct the underlying problem be initiated?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Intervention to correct the underlying primary problem should be performed when the risk of delaying further treatment is greater than the benefit of continuing stabilisation. Complete normalisation may not yet have been achieved.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">When further stabilisation is no longer possible due to ongoing deterioration of the patient’s condition.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">When the patient is stable enough (i.e. not yet normalised) to undergo intervention to correct the primary problem.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">As an example, a patient with septic peritonitis may benefit from surgical treatment before stabilisation to "normal" levels, as it is quite likely that this cannot be achieved before the abdomen has been lavaged.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;"> <ol>
<li>Which emergency situations usually need stabilisation before anaesthetics can be administered?</li>
</ol> </span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Cats with obstructive uropathy that are hyperkalaemic. These cats should have their bladders needle drained and the hyperkalaemia should be resolved before catheterisation under general anaesthetic.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Patients with clinically significant pulmonary contusion (usually following road traffic accidents).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Dogs with GDV should be trocharised and urgently fluid loaded at the same time before an anaesthetic is given. Some of these patients can be stomach tubed by mouth without anaesthetic but most will require at least a short anaesthetic for this. If these dogs are in shock it is my/our opinion that the stomach should be deflated and the vascular compartment fluid and colloid loaded before surgical anaesthetic is administered.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">All patients in shock as a result of trauma that is not resulting in immediate life threatening danger (such as listed above). Fight wounds and dogs involved in motor vehicle accidents are common examples. Adequate resuscitation is normally required before radiographic examinations, wound care or complete assessments can be made. It is important to remember however that a patient that has been injured may only destabilise after admission and as such trauma patients should be closely monitored.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">All dogs with a blood loss anaemia (and MAP below 70 mmHg) or haemolytic anaemia (with haematocrits below 20%)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Pyometra/septic peritonitis cases may need stabilisation although most cases are sufficiently stabile to intervene immediately. The general rule of thumb in any septic patient is to surgically drain or remove the source of sepsis without any or the minimum of delay. Any stabilisation without doing this can be expected to be short lived.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Cases that are clinically dehydrated should be rehydrated in the shortest possible time before urgent anaesthetics are administered.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Cases in low output cardiac failure that is not stable on treatment.</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">8. <span style="text-decoration: underline;">Anaesthesia</span></p>
</strong></p>
<p align="justify">The appropriate use of anaesthetic agents is dependent on the clinical situation of the patient and a thorough knowledge of the clinical pharmacology of drugs used. There is little evidence to support the use of specific drugs and their influence on outcome is negligible. The most important determinate of outcome is the treatment and maintenance of stable cardiovascular and respiratory function (ensuring an adequate oxygen delivery to all cells in the body).</p>
<p align="justify">Essentially patients can be classified into three categories:</p>
<ol>
<li> <ol>
<li> <ol>
<li> <ol>
<li> <ol>
<li>those who are stable may receive a standard induction or slightly reduced induction dose;</li>
<li>those who are unstable should have the anaesthetic slowly titrated to effect;</li>
<li>those who are moribund or near death where minimal anaesthesia should be used.</li>
</ol></li>
</ol></li>
</ol></li>
</ol></li>
</ol>
<p align="justify">General principles to be remembered when anaesthetising compromised patients include the optimisation of tissue perfusion and oxygen delivery to all organ systems while achieving analgesia, muscle relaxation and unconsciousness.</p>
<p><strong>
<p align="justify">A. Pre-anaesthetic Management</p>
</strong></p>
<p align="justify">In certain cases prompt surgical treatment is life saving (uncontrolled haemorrhage, perforated intestines, ruptured pyometra or uterus, etc) but generally the accompanying shock is more dangerous than the initial trauma. In these cases the treatment of shock is the priority before surgical correction is attempted.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Oxygen supplementation</td>
</tr>
</tbody>
</table>
<p align="justify">This is almost always indicated and can be achieved with a facemask, nasal catheter, endotracheal tube or oxygen chamber. The use of an oxygen chamber is not ideal, as it does not allow access to the patient. Oxygen supplementation is especially important in cases with respiratory and cardiac compromise. In anaemic patients correcting haematocrit is more important than oxygen therapy. Remember not to stress animals attempting to administer oxygen. Free flow oxygen passed the face may be the best way of administration in cases that are overly anxious.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Analgesics and sedatives and premedications</td>
</tr>
</tbody>
</table>
<p align="justify">Useful premedications include morphine and diazepam and these are usually indicated. Acetylpromazine and alpha-2 agonists are generally contraindicated. These are required for the management of pain, fear and apprehension. Analgesia should be applied as soon as possible and be maintained post trauma or post-surgery.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Anticholinergics</td>
</tr>
</tbody>
</table>
<p align="justify">These are not routinely used in trauma patients as they increase myocardial oxygen demand and reduce the threshold for arrhythmias. Atropine or glycopyrrolate may be used when vagal influence affect cardiac function or secretions need to be controlled. Trauma patients are often not starved and this increases the incidence of aspiration. Methods to reduce aspiration include position of the head lower than the abdomen, immediate intubation with a cuffed endotracheal tube and suctioning if reflux occurs.</p>
<p><strong>
<p align="justify">B. Induction Agents</p>
</strong></p>
<p align="justify">It is always best to remember that the drug with which you have the most personal experience is most likely to be the safest drug in your hands. Always remember that anaesthetic drugs administered to a patient in shock in the same way as they would be used in a healthy patient will aggravate shock. This is because these drugs have potent respiratory and cardiovascular depressive effects that will exacerbate the state of shock.</p>
<p align="justify">Intravenous agents:</p>
<p align="justify">Barbiturates are known to decrease myocardial contractility, depress baroreceptor reflexes, vasodilatation, decreases venous return and depress respiration. They are poor analgesics and have no muscle relaxation. Barbiturates are arrhythmogenic when given rapidly intravenously. <strong>Propofol</strong> has less of myocardial depressant effect and fewer arrhythmias than <strong>thiopentone.</strong> The degree of myocardial depression is a function of dose and rate of injection. Barbiturates are highly protein bound and the acid-base balance; albumin content and concurrent drug administration influence their pharmacokinetics. Critically ill patients are often acidotic and hypoproteinemic and thus require lower anaesthetic doses.</p>
<p align="justify">Propofol causes similar haemodynamic effects as thiopentone and cannot be recommended over thiopentone unless the patient is cardiovascularly stable.</p>
<p align="justify">Both these agents should be given very slowly intravenously to effect to achieve a plane of anaesthesia just sufficient for intubation. Rapid administration of these agents in states of myocardial hypoxia can be fatal and it is therefore essential to supplement oxygen and ensure adequate blood pressure before induction. Propofol has a greater tendency than thiopentone to cause induction apnoea, especially if given too fast. This may prove fatal in hypoxaemic animals.</p>
<p align="justify">Ketamine is one of the few drugs with indirect cardiovascular stimulatory properties. It raises blood pressure secondary to a sympathetic increase in heart rate and cardiac output. It is contraindicated in any patient with myocardial disease or in a patient in maximal sympathetic stimulation (which is often the case in severe trauma or haemorrhagic shock). Ketamine is a poor muscle relaxant and spontaneous movement is possible. Ketamine increases intracranial pressure and is contra-indicated in cranial trauma. Benzodiazepines may be used with ketamine to enhance muscle relaxation.</p>
<p><strong>
<p align="justify">Opioid induction</p>
</strong></p>
<p align="justify">This mode of induction is the preferred method for induction in compromised patients but needs to be used with caution and a complete description of the use of this modality is beyond the scope of this short review. Opioids are most commonly combined with benzodiazepines and the opioid drugs most commonly used include fentanyl, morphine and midazolam. Mixed agonist-antagonists include buprenorphine and are not preferred due to their ceiling effects and an inability to titrate the analgesia.</p>
<p align="justify">Because opioids (especially fentanyl) result in respiratory depression pre-oxygenation is advisable. Bradycardia may occur and is treatable with anticholinergics and in refractory cases adrenaline may be used. Morphine is associated with a dose dependent histamine release and may result in hypotension. Adequate fluid loading can minimise this negative effect and should not be a reason for withholding morphine administration. Opioid combinations (eg fentanyl and morphine) have been used successfully. Opioid induction (with for example diazepam and fentanyl) is slower than conventional methods and if rapid intubation is required it cannot be recommended. Opioids are administered to the point where tracheal intubation is possible.</p>
<p align="justify">Inhalation agents</p>
<p align="justify">These are as hypotensive as barbiturates and are only safer because the period of time from drug application to surgical anaesthesia is longer thus allowing for a longer period of time for the body to establish homeostasis for their depressant effects on blood pressure. Halothane and isoflurane both cause a dose dependent cardiovascular depression. Isoflurane is the least depressant at equipotent minimum alveolar concentration values. Isoflurane is also less arrhythmogenic and causes a quicker induction than halothane. If a traumatised patient is alert it is likely to struggle with gas induction. This struggle may result in increased circulating catecholamines which may result in arrhythmias (especially with halothane) as halothane sensitises the myocard to adrenaline. Inhalation agents have no muscle relaxing or analgesic properties.</p>
<p align="justify">Some dogs in severe shock require no anaesthesia and only some analgesia in order for surgery to be performed. A less depressant form of analgesia using a local anaesthetic block should be considered. Epidural anaesthesia can be useful tool for abdominal or hind limb procedures. Patients should be fluid loaded as epidural anaesthesia can result in vasodilatation. The lowest possible dose of anaesthetic should be used and all intravenous agents should be titrated to effect.</p>
<p align="justify">Maintenance of anaesthesia.</p>
<p align="justify">Some patients may require mechanical ventilation. The fact that a patient is breathing does not necessarily mean it is adequately ventilating. Remember also that an anaemic, pale patient may not show cyanosis. Close monitoring of the measures of blood pressure, perfusion and tissue oxygenation must be maintained constantly throughout the period of anaesthesia. In addition to close physical assessment of these measures of the patient’s condition, additional monitoring that is very useful includes ECG, pulse oximetery, blood pressure (invasive arterial and or central venous pressure), and capnography. Haemodynamic stability is maintained with fluids, ionotropic agents (dobutamine constant rate infusion), vasoconstrictors (dopamine or adrenalin constant rate infusion) and colloids. Direct arterial blood pressure measurement and central venous pressure can be used to monitor haemodynamic stability. Urinary output is easily monitored with a catheter and is an important indicator of renal perfusion and fluid balance.</p>
<p align="justify">A combination of inhalation agents, opioids, benzodiazepines or ketamine can be given for maintenance.</p>
<p align="justify">Hypothermia kills and patients should be warmed or the body temperature maintained using hot warm bottles, warm water blankets, heating lamps or warm air heating devices during all anaesthetic procedures and post operative care should pay special attention to this aspect.</p>
<p><strong><span style="text-decoration: underline;">
<p align="justify">Useful references include (but are not limited to) the following texts:</p>
</span></strong></p>
<p style="line-height: 100%; ">Manual of Canine and Feline Emergency and Critical Care</p>
<p style="line-height: 100%; " align="justify">Ed: L King, R Hammond.</p>
<p style="line-height: 100%; " align="justify">Published by BSAVA, United Kingdom</p>
<p style="line-height: 100%; " align="justify">1999</p>
<p style="line-height: 100%; " align="justify">ISBN 0 905214 40 4</p>
<p style="line-height: 100%; ">Emergency Medicine in Small Animal Practice</p>
<p style="line-height: 100%; " align="justify">The Compendium Collection</p>
<p style="line-height: 100%; " align="justify">Published by Veterinary Learning Systems, Trenton, New Jersey.</p>
<p style="line-height: 100%; " align="justify">1997</p>
<p style="line-height: 100%; " align="justify">ISBN 1 884254 24 1</p>
<p style="line-height: 100%; ">Small Animal Emergency and Critical Care. A Manual for the Veterinary Technologist.</p>
<p style="line-height: 100%; ">A M Battaglia</p>
<p style="line-height: 100%; " align="justify">Published by WB Saunders Co.</p>
<p style="line-height: 100%; " align="justify">2000</p>
<p style="line-height: 100%; " align="justify">ISBN 0 7216 7773 8</p>
<p style="line-height: 100%; " align="justify">Emergency Procedures for the Small Animal Veterinarian.</p>
<p style="line-height: 100%; " align="justify">SJ Plunkett</p>
<p style="line-height: 100%; " align="justify">WB Saunders, Philadelphia</p>
<p style="line-height: 100%; " align="justify">1993</p>
<p style="line-height: 100%; " align="justify">ISBN 0 7216 6781 3</p>
<p style="line-height: 100%; " align="justify">Self Assessment Colour Review of Small Animal Emergency and Critical Care Medicine.</p>
<p style="line-height: 100%; " align="justify">R Kirbey</p>
<p style="line-height: 100%; " align="justify">Mason Publishing Ltd, London, UK.</p>
<p style="line-height: 100%; " align="justify">1998</p>
<p style="line-height: 100%; " align="justify">ISBN 1 874545 65 6</p>
<p style="line-height: 100%; ">Fluid Therapy in Small Animal Practice. 2<sup>nd</sup> Edition.</p>
<p style="line-height: 100%; " align="justify">Editor: SP DiBartola</p>
<p style="line-height: 100%; " align="justify">WB Saunders Co. Philadelphia</p>
<p style="line-height: 100%; " align="justify">2000</p>
<p style="line-height: 100%; " align="justify">ISBN 0 7216 7739 8.</p>
<p><strong>
<p align="left">Some useful drugs and doses are tabulated below.</p>
</strong></p>
<table border="1" cellspacing="1" width="740" align="left">
<tbody>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"></td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>NAME</strong></p>
</td>
<td width="32%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>DOSAGE</strong></p>
</td>
<td width="15%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>ROUTE</strong></p>
</td>
<td width="14%" height="18" valign="middle" bgcolor="#c0c0c0"><strong> </strong>
<p align="center"><strong>STRENGTH</strong></p>
</td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"><strong> </strong>
<p align="center"><strong>PREMEDICATION</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>ATROPINE SULPHATE</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>0.02 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>0.5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>(ATORPINE)</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>0.04 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">s/c</p>
</td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>MIDAZOLAM</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>0.3 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/m or i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>DIAZEPAM</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>0.2 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"></td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"><strong> </strong>
<p align="center"><strong>INDUCTION</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>THIOPENTONE SODIUM</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>10 mg/kg (with premed)</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>25 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom">
<p>15 mg/kg (without premed)</p>
</td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>PROPOFOL</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>4 - 6 mg/kg (with premed)</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>10 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>6-8 mg/kg (without premed)</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>KETAMINE</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>5 - 10 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p>100 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom">
<p>10 - 20 mg/kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/m</p>
</td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>FENTANYL</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>40 microgram/kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/m or i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>0.2 mg/ml</p>
</td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"><strong> </strong>
<p><strong>OTHER</strong></p>
</td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="middle" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>ADRENALINE</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>1 ml/10 kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">1/1000</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom">
<p>ATROPINE</p>
</td>
<td width="32%" height="18" valign="bottom">
<p>1 ml/10 kg</p>
</td>
<td width="15%" height="18" valign="bottom">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom">
<p align="center">0.5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>LIGNOCAINE</p>
</td>
<td width="32%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p>1 ml/10 kg</p>
</td>
<td width="15%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">i/v</p>
</td>
<td width="14%" height="18" valign="bottom" bgcolor="#c0c0c0">
<p align="center">2%</p>
</td>
</tr>
<tr>
<td colspan="4" height="18" valign="bottom"></td>
</tr>
<tr>
<td width="40%" height="18" valign="bottom"></td>
<td width="32%" height="18" valign="bottom"></td>
<td width="15%" height="18" valign="bottom"></td>
<td width="14%" height="18" valign="bottom"></td>
</tr>
<tr>
<td colspan="4" height="18" valign="middle"><strong> </strong>
<p align="center"><strong>ANALGESICS</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>MORPHINE SULPHATE</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0">
<p>0.2-0.4 mg/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0">
<p>s/c or i/v</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0">
<p>10 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>(MORPHINE)</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>FENTANYL</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0">
<p>10 – 20 microgram/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0">
<p>i/m or i/v</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0">
<p>0.2 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="top">
<p>BUPRENORPHINE</p>
</td>
<td width="32%" height="18" valign="top">
<p>0.02 mg/kg</p>
</td>
<td width="15%" height="18" valign="top">
<p>i/m</p>
</td>
<td width="14%" height="18" valign="top">
<p>0.3 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top"></td>
<td width="32%" height="18" valign="top"></td>
<td width="15%" height="18" valign="top"></td>
<td width="14%" height="18" valign="top"></td>
</tr>
<tr>
<td colspan="4" height="18" valign="top"><strong> </strong>
<p align="center"><strong>EPIDURALS</strong></p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>MORPHINE SULPHATE</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0">
<p>0.1 mg/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0">
<p>EPIDURAL</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0">
<p>10 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#c0c0c0">
<p>(MORPHINE)</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="15%" height="18" valign="top" bgcolor="#c0c0c0"></td>
<td width="14%" height="18" valign="top" bgcolor="#c0c0c0"></td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#ffffff">
<p>ROPIVACAINE</p>
</td>
<td width="32%" height="18" valign="top" bgcolor="#ffffff">
<p>1 mg/kg</p>
</td>
<td width="15%" height="18" valign="top" bgcolor="#ffffff">
<p>EPIDURAL</p>
</td>
<td width="14%" height="18" valign="top" bgcolor="#ffffff">
<p>7.5 mg/ml</p>
</td>
</tr>
<tr>
<td width="40%" height="18" valign="top" bgcolor="#ffffff"></td>
<td width="32%" height="18" valign="top" bgcolor="#ffffff"></td>
<td width="15%" height="18" valign="top" bgcolor="#ffffff"></td>
<td width="14%" height="18" valign="top" bgcolor="#ffffff"></td>
</tr>
</tbody>
</table>
<p align="left"><em>(Published Newsletter 38, November 2004)</em></p></div>Guidelines - Anaesthesia: Monitoring2009-09-02T11:00:12+00:002009-09-02T11:00:12+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/241-guidelines-anaesthesia-monitoringAdministratorwebmaster@savc.org.za<div class="feed-description"><p align="center"><strong>Anaesthesia: Monitoring</strong></p>
<p align="center"><strong>ANAESTHESIA</strong></p>
<p align="left">The following guideline should be followed for the monitoring of animals under anaesthesia: The monitoring, maintenance and recovery from anaesthesia should be effected by registered personnel and or trained non registered personnel under supervision of a registered veterinarian who must be on the premises. Surgery, monitoring and maintenance should not be done by the same person.</p>
<p align="left">All animals should be monitored after surgery and not discharged unless adequately recovered from anaesthesia. All animals must be fully conscious and ambulatory before discharging them from an animal facility.</p>
<p align="center"><em><strong>Should it be necessary for a practitioner to deviate from the aforementioned the owner should be advised of the risks involved.</strong></em></p>
<p align="left"><em>(Published -December 1997)</em></p>
<p align="left">Refer to the guideline document under <strong>Guidelines</strong> titled " Recommendations for Monitoring of Anaesthesia" below.</p>
<p align="center"><strong> Anaesthesia: Starving Patients</strong></p>
<p align="left">The delay or postponement of appropriate treatment of an emergency or other condition which, if not given timeous attention, could result in unwanted complications and lead to a veterinarian being found guilty at an inquiry. Rule 4.1.2 of the Veterinary and Para-Veterinary Professions Act determines that <span style="text-decoration: underline;">a veterinarian is morally obliged to serve the public to the best of his/ her ability and in terms of the latest scientific knowledge.</span> It is clear that there can be no grounds for defence on the basis of outdated information. One example is the delay of general anaesthesia for fear that complications may develop in an animal who has recently eaten.</p>
<p align="left"><em>(Published - August 2000)</em></p>
<p><strong>
<p align="center">Anaesthetic Gas Scavenging</p>
</strong></p>
<p align="center">KE Joubert MMedVet (Anaes), BVSc</p>
<p align="center">Anaesthesiology: Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria</p>
<p align="center">Private Bag X04, Onderstepoort, 0110, RSA, (012) 529 8137 (Office), (012) 529 8307 (Fax), <a href="mailto:Kjoubert@op.up.ac.za">Kjoubert@op.up.ac.za</a></p>
<p align="justify">A number of practitioners have disputed the relevance and practicality of scavenging of waste anaesthetic gas from operating theatres. In a recent survey of 161 practitioners in South Africa it came to light that only 11.8% of practitioners applied any form of scavenging to prevent contamination of the operating room environment. Volatile anaesthetic agents and some carrier gases may pose a significant health risk for staff. The welfare of animals, employees, and the clients are the concern of the veterinary profession and its governing institution.</p>
<p align="justify">The Occupational Health and Safety Act of RSA (Act 85 of 1993 as amended by Act 181 of 1993), requires that every employer instructs employees on the hazards to their health with regard to any substance they may use, handle, store or transport (Section 8, 9 and 12). As halothane or any of the other volatile anaesthetic agents are considered a potential health risk which is augmented by the fact that the European Union and the United Sates have established maximum exposure levels, we as employers are required to take the necessary precautions as described in Act 85 of 1993. The act requires that the employer instruct the employee on the appropriate methods to handle and use hazardous substances and it also states that an employer must take appropriate measures to prevent unnecessary exposure to any hazardous substance. Failure do so, is considered under the act to be an offence. Veterinarians are advised to take cognisance of this fact as litigation may result. The council by encouraging scavenging of anaesthetic agents wishes to protect veterinarians from potential legal consequences. The Occupational Health and Safety Act is administered by the Department of Labour.</p>
<p align="justify">Active scavenging devices are expensive and are not mandatory for veterinary facilities. Simple passive scavenging systems can be implemented as follows:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A pipe is connected to the pressure relief valve (pop-off valve) and another conduit through the outside wall of the room at a level below the height of the anaesthetic machine.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Installation of an activated charcoal container on the anaesthetic machine absorbs exhaled anaesthetic gasses. Companies specialising in this kind of equipment must install this. Like the soda-lime canister, the activated charcoal must be replaced from time to time. It is also a more costly system but convenient for mobile anaesthetic machines.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Alternative a plastic refuse bag (good quality) can also be attached to the pop-off valve and emptied outside after the procedure.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">In cases where gas masks are used (like birds) anaesthetic gases escape into the room and there is an even greater potential for risk. In these cases it is recommended that a well-ventilated room be used, the masks fits a tightly as possible and if attached to breathing circuit scavenging is possible.</td>
</tr>
</tbody>
</table>
<p><strong>
<p>Acknowledgement</p>
</strong></p>
<p align="justify">This article has been based on a previous publication by the author: Joubert KE 1999 The hidden dangers of the anaesthetic machine. <em>Journal of the South African Veterinary Association</em>: 70: 4: 140 – 141. Prof AM Lübbe is acknowledged for his input into the article. A list of references is available on request.</p>
<p align="justify"><em>(Published - A</em><em>pril 2003)</em></p></div><div class="feed-description"><p align="center"><strong>Anaesthesia: Monitoring</strong></p>
<p align="center"><strong>ANAESTHESIA</strong></p>
<p align="left">The following guideline should be followed for the monitoring of animals under anaesthesia: The monitoring, maintenance and recovery from anaesthesia should be effected by registered personnel and or trained non registered personnel under supervision of a registered veterinarian who must be on the premises. Surgery, monitoring and maintenance should not be done by the same person.</p>
<p align="left">All animals should be monitored after surgery and not discharged unless adequately recovered from anaesthesia. All animals must be fully conscious and ambulatory before discharging them from an animal facility.</p>
<p align="center"><em><strong>Should it be necessary for a practitioner to deviate from the aforementioned the owner should be advised of the risks involved.</strong></em></p>
<p align="left"><em>(Published -December 1997)</em></p>
<p align="left">Refer to the guideline document under <strong>Guidelines</strong> titled " Recommendations for Monitoring of Anaesthesia" below.</p>
<p align="center"><strong> Anaesthesia: Starving Patients</strong></p>
<p align="left">The delay or postponement of appropriate treatment of an emergency or other condition which, if not given timeous attention, could result in unwanted complications and lead to a veterinarian being found guilty at an inquiry. Rule 4.1.2 of the Veterinary and Para-Veterinary Professions Act determines that <span style="text-decoration: underline;">a veterinarian is morally obliged to serve the public to the best of his/ her ability and in terms of the latest scientific knowledge.</span> It is clear that there can be no grounds for defence on the basis of outdated information. One example is the delay of general anaesthesia for fear that complications may develop in an animal who has recently eaten.</p>
<p align="left"><em>(Published - August 2000)</em></p>
<p><strong>
<p align="center">Anaesthetic Gas Scavenging</p>
</strong></p>
<p align="center">KE Joubert MMedVet (Anaes), BVSc</p>
<p align="center">Anaesthesiology: Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria</p>
<p align="center">Private Bag X04, Onderstepoort, 0110, RSA, (012) 529 8137 (Office), (012) 529 8307 (Fax), <a href="mailto:Kjoubert@op.up.ac.za">Kjoubert@op.up.ac.za</a></p>
<p align="justify">A number of practitioners have disputed the relevance and practicality of scavenging of waste anaesthetic gas from operating theatres. In a recent survey of 161 practitioners in South Africa it came to light that only 11.8% of practitioners applied any form of scavenging to prevent contamination of the operating room environment. Volatile anaesthetic agents and some carrier gases may pose a significant health risk for staff. The welfare of animals, employees, and the clients are the concern of the veterinary profession and its governing institution.</p>
<p align="justify">The Occupational Health and Safety Act of RSA (Act 85 of 1993 as amended by Act 181 of 1993), requires that every employer instructs employees on the hazards to their health with regard to any substance they may use, handle, store or transport (Section 8, 9 and 12). As halothane or any of the other volatile anaesthetic agents are considered a potential health risk which is augmented by the fact that the European Union and the United Sates have established maximum exposure levels, we as employers are required to take the necessary precautions as described in Act 85 of 1993. The act requires that the employer instruct the employee on the appropriate methods to handle and use hazardous substances and it also states that an employer must take appropriate measures to prevent unnecessary exposure to any hazardous substance. Failure do so, is considered under the act to be an offence. Veterinarians are advised to take cognisance of this fact as litigation may result. The council by encouraging scavenging of anaesthetic agents wishes to protect veterinarians from potential legal consequences. The Occupational Health and Safety Act is administered by the Department of Labour.</p>
<p align="justify">Active scavenging devices are expensive and are not mandatory for veterinary facilities. Simple passive scavenging systems can be implemented as follows:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A pipe is connected to the pressure relief valve (pop-off valve) and another conduit through the outside wall of the room at a level below the height of the anaesthetic machine.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Installation of an activated charcoal container on the anaesthetic machine absorbs exhaled anaesthetic gasses. Companies specialising in this kind of equipment must install this. Like the soda-lime canister, the activated charcoal must be replaced from time to time. It is also a more costly system but convenient for mobile anaesthetic machines.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Alternative a plastic refuse bag (good quality) can also be attached to the pop-off valve and emptied outside after the procedure.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">In cases where gas masks are used (like birds) anaesthetic gases escape into the room and there is an even greater potential for risk. In these cases it is recommended that a well-ventilated room be used, the masks fits a tightly as possible and if attached to breathing circuit scavenging is possible.</td>
</tr>
</tbody>
</table>
<p><strong>
<p>Acknowledgement</p>
</strong></p>
<p align="justify">This article has been based on a previous publication by the author: Joubert KE 1999 The hidden dangers of the anaesthetic machine. <em>Journal of the South African Veterinary Association</em>: 70: 4: 140 – 141. Prof AM Lübbe is acknowledged for his input into the article. A list of references is available on request.</p>
<p align="justify"><em>(Published - A</em><em>pril 2003)</em></p></div>Guidelines - Advertising2009-09-02T10:50:23+00:002009-09-02T10:50:23+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/240-guidelines-advertisingAdministratorwebmaster@savc.org.za<div class="feed-description"><p style="text-align: center;"><strong>Advertising<br /><br />ADVERTISEMENTS AND ARTICLES</strong></p>
<p><br />Refer to the new rules published on 18 January 2002. Go to the web page for veterinarians and click on Advertising. Fees and incentives shall not be the subject of any advertisement. Prices of products, merchandise and foodstuffs sold and non-professional services rendered at the facility may, however be advertised.<br /><br />It would be regarded as unprofessional conduct if collusion was proved by a veterinarian to ensure that his/her advertisement appeared next to an article / advertorial by a third party if the article was considered as touting. Members may use their titles, names and surnames and qualifications inscribed into the register when an articles are published in the lay press e.g. Dr John Morgan, BVSc. <br /><br />Please submit any advertisements or articles to Council for approval if you are not sure about the interpretation of the rule.</p></div><div class="feed-description"><p style="text-align: center;"><strong>Advertising<br /><br />ADVERTISEMENTS AND ARTICLES</strong></p>
<p><br />Refer to the new rules published on 18 January 2002. Go to the web page for veterinarians and click on Advertising. Fees and incentives shall not be the subject of any advertisement. Prices of products, merchandise and foodstuffs sold and non-professional services rendered at the facility may, however be advertised.<br /><br />It would be regarded as unprofessional conduct if collusion was proved by a veterinarian to ensure that his/her advertisement appeared next to an article / advertorial by a third party if the article was considered as touting. Members may use their titles, names and surnames and qualifications inscribed into the register when an articles are published in the lay press e.g. Dr John Morgan, BVSc. <br /><br />Please submit any advertisements or articles to Council for approval if you are not sure about the interpretation of the rule.</p></div>Guidelines - Admissions to Veterinary Clinical Facilities2009-09-02T10:48:46+00:002009-09-02T10:48:46+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/239-guidelines-admissions-to-veterinary-clinical-facilitiesAdministratorwebmaster@savc.org.za<div class="feed-description"><p style="text-align: center;"><strong>Admissions to Veterinary Clinical Facilities<br /><br />HOSPITAL ADMISSIONS</strong></p>
<p><br /><br />What Council expects from a veterinarian when an animal is admitted to a facility for treatment and care.<br /><br />The companion animal practitioner leaves his patients not fully recovered from surgery or the rural practitioner spays a dog at 7:00 and then leaves on farm calls.<br /><br />It is expected of the veterinarian to ensure that the animal is monitored by an adequately trained person and that the veterinarian or his / her colleague attends to the patient at least once a day over and above the surgery performed on the animal. <br /><br />Most practitioners leave their practices at 7:00 p.m. and patients are left on their own.<br /><br />An animal should not be hospitalised over night at a clinic except if full-time supervision is available ( by an adequately trained person) at the clinic / hospital concerned. <br /><br />(Published -August 2000)<br /><br /><br /><br /><br /><br /></p></div><div class="feed-description"><p style="text-align: center;"><strong>Admissions to Veterinary Clinical Facilities<br /><br />HOSPITAL ADMISSIONS</strong></p>
<p><br /><br />What Council expects from a veterinarian when an animal is admitted to a facility for treatment and care.<br /><br />The companion animal practitioner leaves his patients not fully recovered from surgery or the rural practitioner spays a dog at 7:00 and then leaves on farm calls.<br /><br />It is expected of the veterinarian to ensure that the animal is monitored by an adequately trained person and that the veterinarian or his / her colleague attends to the patient at least once a day over and above the surgery performed on the animal. <br /><br />Most practitioners leave their practices at 7:00 p.m. and patients are left on their own.<br /><br />An animal should not be hospitalised over night at a clinic except if full-time supervision is available ( by an adequately trained person) at the clinic / hospital concerned. <br /><br />(Published -August 2000)<br /><br /><br /><br /><br /><br /></p></div>Guidelines - Animal Experimentation2009-09-02T10:48:02+00:002009-09-02T10:48:02+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/238-guidelines-animal-experimentationAdministratorwebmaster@savc.org.za<div class="feed-description"><p align="center"><strong>Animal Experimentation</strong></p>
<p align="center"><strong>ANIMAL EXPERIMENTATION</strong></p>
<p align="left">Animal experimentation according to modern scientific principles has been going on for over a century. The results in surgery, medicine, infectious diseases, pharmacology and other disciplines have been of enormous benefit to both animals and humans. They have also had cumulative affects of accelerating knowledge in many directions as one discovery leads to another.</p>
<p align="left"><strong>The SAVC believes that animal experimentation has and will continue to form the basis of much veterinary and medical knowledge.</strong></p>
<p align="left">With rare exceptions, mammalian anatomy and physiology share many more similarities than differences. Responses in toxicity and efficacy trials are indeed reliable for screening products for possible use in humans and other animals. The same principles apply to surgical and diagnostic procedures, including modern imaging techniques.</p>
<p align="left">The relief of human and animal suffering and the saving of lives far outweigh the relatively small sacrifices in animal experiments. As an example, many millions of humans and animals have been treated successfully for diabetes since the discovery of insulin by <em>Best and Banting </em>in 1921 and their experiments in animals. In this example the hormone involved and the responses to it are remarkably similar between the species. The same has been true for countless other experiments.</p>
<p align="left">New knowledge often has the surprising result of being applicable to humans or animals in unpredictable and unforeseen ways. It may therefore be considered good in itself because of the options and possibilities it opens up. Animal experimentation that is directed at solving human problems also benefits animals because of the knowledge gained in technique, materials and use of medicines.</p>
<p align="left">For these reasons the SAVC believes it to be irrational for veterinarians to deny a very large part of their present and future foundation of knowledge.</p>
<p align="left"><strong>It is aware of the possibility of abuse and subscribes to the principles of the National Code on Animal Experimentation.</strong></p>
<p align="left">Adherence to this code will result in: -</p>
<ol>
<li>
<p align="left">No unnecessary or duplicated experiments;</p>
</li>
<li>
<p align="left">Protocols that ensure the use of minimum number of animals with minimal suffering and sacrifice;</p>
</li>
<li>
<p align="left">A transparency that ensures high quality ethical and scientific screening of proposals and monitoring of experiments as they are performed.</p>
</li>
</ol>
<p align="left">The SAVC also supports replacement of animal experimentation with alternative experimental technology whenever possible as well as refinement of animal experimental protocols to further limit suffering and sacrifice.</p>
<p align="left">The SAVC is involved in initiatives to plan new legislation based on the National Code on Animal Experimentation which will include a regulating Council and institutional Animal Ethics Committees in all institutions which conduct experiments. Such committees will have mandatory involvement of veterinarians and animal welfare representatives.</p>
<p align="left"><em>(Published June 1997, courtesy of Dr P C Ardington)</em></p>
<p> </p></div><div class="feed-description"><p align="center"><strong>Animal Experimentation</strong></p>
<p align="center"><strong>ANIMAL EXPERIMENTATION</strong></p>
<p align="left">Animal experimentation according to modern scientific principles has been going on for over a century. The results in surgery, medicine, infectious diseases, pharmacology and other disciplines have been of enormous benefit to both animals and humans. They have also had cumulative affects of accelerating knowledge in many directions as one discovery leads to another.</p>
<p align="left"><strong>The SAVC believes that animal experimentation has and will continue to form the basis of much veterinary and medical knowledge.</strong></p>
<p align="left">With rare exceptions, mammalian anatomy and physiology share many more similarities than differences. Responses in toxicity and efficacy trials are indeed reliable for screening products for possible use in humans and other animals. The same principles apply to surgical and diagnostic procedures, including modern imaging techniques.</p>
<p align="left">The relief of human and animal suffering and the saving of lives far outweigh the relatively small sacrifices in animal experiments. As an example, many millions of humans and animals have been treated successfully for diabetes since the discovery of insulin by <em>Best and Banting </em>in 1921 and their experiments in animals. In this example the hormone involved and the responses to it are remarkably similar between the species. The same has been true for countless other experiments.</p>
<p align="left">New knowledge often has the surprising result of being applicable to humans or animals in unpredictable and unforeseen ways. It may therefore be considered good in itself because of the options and possibilities it opens up. Animal experimentation that is directed at solving human problems also benefits animals because of the knowledge gained in technique, materials and use of medicines.</p>
<p align="left">For these reasons the SAVC believes it to be irrational for veterinarians to deny a very large part of their present and future foundation of knowledge.</p>
<p align="left"><strong>It is aware of the possibility of abuse and subscribes to the principles of the National Code on Animal Experimentation.</strong></p>
<p align="left">Adherence to this code will result in: -</p>
<ol>
<li>
<p align="left">No unnecessary or duplicated experiments;</p>
</li>
<li>
<p align="left">Protocols that ensure the use of minimum number of animals with minimal suffering and sacrifice;</p>
</li>
<li>
<p align="left">A transparency that ensures high quality ethical and scientific screening of proposals and monitoring of experiments as they are performed.</p>
</li>
</ol>
<p align="left">The SAVC also supports replacement of animal experimentation with alternative experimental technology whenever possible as well as refinement of animal experimental protocols to further limit suffering and sacrifice.</p>
<p align="left">The SAVC is involved in initiatives to plan new legislation based on the National Code on Animal Experimentation which will include a regulating Council and institutional Animal Ethics Committees in all institutions which conduct experiments. Such committees will have mandatory involvement of veterinarians and animal welfare representatives.</p>
<p align="left"><em>(Published June 1997, courtesy of Dr P C Ardington)</em></p>
<p> </p></div>Guidelines - The Chemical Restraint Of Vicious Dogs2009-09-02T10:46:03+00:002009-09-02T10:46:03+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/237-guidelines-the-chemical-restraint-of-vicious-dogsAdministratorwebmaster@savc.org.za<div class="feed-description"><p><strong>
<p align="center">THE CHEMICAL RESTRAINT OF VICIOUS DOGS</p>
</strong></p>
<p align="center">KE Joubert MMedVet (Anaes), BVSc Anaesthesiology: Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, U. P.</p>
<p align="center">Private Bag X04, Onderstepoort, 0110, RSA, (012) 529 8137 (Office), (012) 529 8307 (Fax), <a href="mailto:Kjoubert@op.up.ac.za">Kjoubert@op.up.ac.za</a></p>
<p><strong>
<p>Introduction</p>
</strong></p>
<p align="justify">The intention of this document is to review the various options available for chemical restrain vicious dogs. It is important to realise from the outset that your safety is of particular importance. When administering drugs to aggressive patients, care should be taken to prevent the dog from attacking you. More importantly however it should be ensured that the dog does not attack the owner. This consequence may have legal implications for the veterinarian. Intramuscular drugs are preferably administered by a poll syringe from a distance or a dart gun may be used. If dogs can be restrained manually, intravenous access may be readily obtained and drugs may be administered intravenously.</p>
<p align="justify">My technique for aggressive dogs that can be manually restrained is to obtain intravenous access in either the cephalic or the saphenus vein. This is followed by the intravenous administration of thiopentone in healthy dogs, endotracheal intubation and the administration of halothane. This option is usually only available in dogs that have been well trained.</p>
<p><strong>
<p>Acetylpromazine</p>
</strong></p>
<p align="justify">Many veterinarians use acetylpromazine to sedate aggressive dogs. Very often tablets are given to owners to administer to the dog at home before bringing it to the consulting room. Although this has been successful in many cases this practice is ill-advised. Acetylpromazine is a tranquilliser and as such has a ceiling sedative effect. Clinically this means that sedation increases to a point beyond which no increase is clinically seen. Acetylpromazine is also an anxiolytic. Anxious dogs may be prevented from biting by the administration of acetylpromazine. Increasing doses of acetylpromazine cause the dog to become collapsed due to hypotension. Any increase in adrenergic tone will briefly reverse the hypotension giving the dog enough strength to bite someone. But more importantly, acetylpromazine may make aggressive dogs even more aggressive by the removal of fear. There are reports in the literature of this effect and hence acetylpromazine should be avoided in aggressive animals. If a veterinarian were to prescribe acetylpromazine to an aggressive dog and the dog was to bite the owner then there may very well be legal ramifications as this effect has been documented.</p>
<p align="justify">The sedative effects of acetylpromazine can be increased by combining acetylpromazine with opioids (a neurolept combination). Appropriate opioids that can be used include morphine, fentanyl and buprenorphine. Buprenorphine takes approximately 30 minutes to reach its peak effect and hence should be given in advance. After the administration of a neurolept combination the animals should be allowed to quietly rest until the drugs have exerted full effect. Neuroleptic combinations may even be administered intramuscularly or intravenously.</p>
<p><strong>
<p>Alpha<sub>2</sub> Agonists</p>
</strong></p>
<p align="justify">The alpha<sub>2</sub> agonists are potent sedatives in small animals. The alpha<sub>2</sub> agonists are known to cause cardiovascular disturbances. The cardiovascular disturbances include an initial hypertension followed by slowing of the heart rate (bradycardia), SA and AV blocks, and a reduction in cardiac output. These cardiovascular changes may be detrimental in a compromised patient. Respiratory depression is also evident after the administration of these drugs. The intramuscular administration of the alpha<sub>2</sub> agonists will usually result in good sedation. That is provided the animal is allowed to relax in a stress free environment after the administration of the alpha<sub>2</sub> agonist. Failure to do this resulted inadequate sedation. Some dogs may still respond to painful stimuli and stress with an aggressive reaction after the administration of an alpha<sub>2</sub> agonist alone. The sedative action of alpha<sub>2</sub> agonist can be increased by the administration of an opioid, similar to that of the neuroleptic combination. If anaesthesia is to be induced after the administration of an alpha<sub>2</sub> agonist the dose of the anaesthetic agent should be carefully titrated to effect to avoid an accidental overdose. All the alpha<sub>2</sub> agonists are reversible bringing an element of safety.</p>
<p align="justify">As an alternative, alpha<sub>2</sub> agonists can be administered with ketamine intramuscularly to induce anesthesia. Such a combination can be administered through a pole syringe. An additional dose of thiopentone or propofol may be required for the endotracheal intubation.</p>
<p align="justify">Alpha<sub>2</sub> agonists may also be administered orally. The drug should be administered preferably sublingually as rapid absorption takes place. The dose of alpha<sub>2</sub> agonist needs to be increased by two to fourfold for an optimal effect. Again the patient needs to be left in a quiet stress free environment for approximately 30 minutes before it is handled.</p>
<p align="justify">Alpha<sub>2</sub> agonists have been successfully used subcutaneously in animals. The subcutaneous administration may be more easily accomplished. Again sufficient time must be allowed for the drug to take effect before the animal is handled.</p>
<p><strong>
<p>Zolazepam/Tiletamine</p>
</strong></p>
<p align="justify">This is another useful combination for aggressive dogs. The drug may be administered intramuscularly to produce profound sedation or anaesthesia for 30 – 60 minutes. The drug combination may also be administered orally to animals in a small quantity of food or sprayed into the mouth. The patient should then be allowed to become sedated in a quiet stress free environment. The cardiovascular stability of this drug combination is good.</p>
<p><strong>
<p>Pentobarbitone</p>
</strong></p>
<p>Pentobarbitone can be administered orally to animals. The dose required is quite large, between 40 and 80 mg/kg. The time for this drug to achieve its full effect may be well over an hour.</p>
<p align="center"> </p>
<table border="1" cellspacing="3" cellpadding="7" width="328">
<tbody>
<tr>
<td width="61%" valign="top">
<p><strong>Drugs</strong></p>
</td>
<td width="39%" valign="top"><strong> </strong>
<p><strong>Dose Rate </strong></p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Acetylpromazine</p>
</td>
<td width="39%" valign="top">
<p>0.01 – 0.5 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Buprenorphine</p>
</td>
<td width="39%" valign="top">
<p>0.01 – 0.03 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Ketamine</p>
</td>
<td width="39%" valign="top">
<p>10 – 30 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Medetomidine</p>
</td>
<td width="39%" valign="top">
<p>0.01 – 0.1 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Morphine</p>
</td>
<td width="39%" valign="top">
<p>0.1 – 1 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Pentobarbitone</p>
</td>
<td width="39%" valign="top">
<p>10 – 80 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Xylazine</p>
</td>
<td width="39%" valign="top">
<p>0.5 – 1 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Zolazepam/tiletamine</p>
</td>
<td width="39%" valign="top">
<p>0.5 – 1 mg/kg</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="center">Table 1: Drugs Dose rates. The following are suggested drug dose rates. Routes of administration and the clinical condition need to be considered when administering these agents. 1.</p>
<p>References</p>
</strong>1.Anash, O. B., Raekallio, M. and Vainio, O. 1998 Comparison of three doses of dexmedetomidine with medetomidine in cats following intramuscular administration. <em>Journal of Veterinary Pharmacology and Therapeutics</em> 21: 380 - 387.</p>
<p>2.Bergström, K. 1988 Cardiovascular and pulmonary effects of a new sedative/analgesic (medetomidine) as a preanaesthetic drug in the dog. <em>Acta Veterinaria Scandanavia</em> 29: 109 - 116.</p>
<p>3. Collard, J. A. 1958 Unusual reaction to chlorpromazine hydrochloride in a bitch. <em>Australian Veterinary Journal</em> 34: 90.</p>
<p>4.Dohoo, S. E., O'Connor, M. K., McDonell, W. N. and Dohoo, I. R. 1986 A clinical comparison of oxymorphone / acepromazine and fentanyl / droperidol sedation in dogs. <em>Journal of the American Animal Hospital Association</em> 22: 313 - 317.</p>
<p>5.Farver, T. B., Haskins, S. C. and Patz, J. D. 1986 Cardiopulmonary effects of acepromazine and of the subsequent administration of ketamine in the dog. <em>American Journal of Veterinary Research</em> 47: 3: 631 - 635.</p>
<p>6.Grimm, J. B., Grimm, K. A., Kneller, S. K., Tranquilli, W. J., Crochik, S. S., Bischoff, M. G. and Podolski, J. L. 2001 The effect of a combination of medetomidine-butorphanol and medetomidine, butorphanol, atropine on glomerular filtration rate in dogs. <em>Veterinary Radiology and Ultrasound</em> 42: 5: 458 - 462.</p>
<p>7.Hamlin, R. L. and Bednarski, L. M. 1989 Studies to determine the optimal dose of medetomidine in dogs. <em>Acta Veterinaria Scandanavia</em> 85: 89 - 95.</p>
<p>8. Hatch, R. C., Clark, J. D., Booth, N. H. and Kitzman, J. V. 1983 Comparison of five preanesthetic medicaments in pentobarbital-anesthetized dogs: antagonism by 4-aminopyridine, yohimbine, and naloxone. <em>American Journal of Veterinary Research</em> 44: 12: 2312 - 2319.</p>
<p>9. Hellyer, P., Muir, W. W., Hubbell, J. A. E. and Sally, J. 1988 Cardiorespiratory effects of the intravenous administration of tiletamine - zolazepam to cats. <em>Veterinary Surgery</em> 17: 2: 105 - 110.</p>
<p>10. Hellyer, P., Muir, W. W., Hubbell, J. A. E. and Sally, J. 1989 Cardiorespiratoy effects of the intravenous administration of tiletamine - zolazepam to dogs. <em>Veterinary Surgery</em> 18: 2: 160 - 165.</p>
<p>11. Klide, A. M., Calderwood, H. W. and Soma, L. R. 1975 Cardiopulmonary effects of xylazine in dogs. <em>American Journal of Veterinary Research</em> 36: 7: 931 - 935.</p>
<p>12. Ko, J. C. H., Bailey, J. E., Pablo, L. S. and Heaton-Jones, T. G. 1996 Comparison of sedative and cardiorespiratory effects of medetomidine and medetomidine-butorphanol combination in dogs. <em>American Journal of Veterinary Research</em> 57: 4: 535 - 540.</p>
<p>13. Ko, J. C. H., Fox, S. M. and Mandsager, R. E. 2000 Sedative and cardiorespiratory effects of medetomidine, medetomidne-butorphanol, and medetomidine-ketamine in dogs. <em>Journal of the American Veterinary Medical Association</em> 216: 10: 1578 - 1583.</p>
<p>14. Lamont, L. A., Bulmer, B. J., Grimm, K. A., Tranquilli, W. J. and Sisson, D. D. 2001 Cardiopulmonary evaluation of the use of medetomidine hydrochloride in cats. <em>American Journal of Veterinary Research</em> 62: 11: 1745 - 1749.</p>
<p>15. Meyer, E. K. 1997 Rare idiosyncratic reaction to acepromazine in dogs. <em>Journal of the American Veterinary Medical Association</em> 210: 8: 1114 - 1115.</p>
<p>16. Moens, Y. and Fargetton, X. 1990 A comparative studt of medetomidine/ketamine and xylazine/ketamine in dogs. <em>Veterinary Record</em> 127: 567 - 571.</p>
<p>17. Raiha, M. P., Raiha, J. and Short, C. E. 1989 A comparison of xylazine, acepromazine, meperidine and medetomidine as preanesthetics to halothane anesthesia in dogs. <em>Acta Veterinaria Scandanavia</em> 85: 97 - 102.</p>
<p>18. Ramsay, E. C. and Wetzel, R. W. 1998 Comparison of five regimens for oral administration of medication to induce sedation in dogs prior to euthanasia. <em>Journal of the American Veterinary Medical Association</em> 213: 2: 240 - 242.</p>
<p>19. Robertson, S. A., Hauptman, J. G., Nachreiner, R. F. and Richter, M. A. 2001 Effects of acetylpromazine or morphine on urine production in halothane-anesthetized dogs. <em>American Journal of Veterinary Research</em> 62: 12: 1922 - 1927.</p>
<p>20. Robinson, K. J., Jones, R. S. and Cripps, P. J. 2001 Effects of medetomidine and buprenorphine administered for sedation in dogs. <em>Journal of Small Animal Practice</em> 42: 444 - 447.</p>
<p>21. Vickery, R. G., Sheridan, B. C., Segal, I. S. and Maze, M. 1988 Anesthetic and hemodynamic effects of the sterioisomers of medetomidine, an <sub>2</sub>-adrenergic agonist, in halothane-anesthetized dogs. <em>Anesthesia and Analgesia</em> 67: 611 - 615.</p>
<p>22. Waechter, R. A. 1982 Unusual reaction to acepromazine maleate in the dog. <em>Journal of the American Veterinary Medical Association</em> 180: 1: 73 - 74.</p>
<p>23.Wetzel, R. W. and Ramsay, E. C. 1998 Comparison of four regimens for intraoral administration of medication to induce sedation in cats prior to euthanazia. <em>Journal of the American Veterinary Medical Association</em> 213: 2: 243 - 245.</p>
<p><em>(Published - April 2003, courtesy of Dr K E Joubert)</em></p>
<p> </p></div><div class="feed-description"><p><strong>
<p align="center">THE CHEMICAL RESTRAINT OF VICIOUS DOGS</p>
</strong></p>
<p align="center">KE Joubert MMedVet (Anaes), BVSc Anaesthesiology: Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, U. P.</p>
<p align="center">Private Bag X04, Onderstepoort, 0110, RSA, (012) 529 8137 (Office), (012) 529 8307 (Fax), <a href="mailto:Kjoubert@op.up.ac.za">Kjoubert@op.up.ac.za</a></p>
<p><strong>
<p>Introduction</p>
</strong></p>
<p align="justify">The intention of this document is to review the various options available for chemical restrain vicious dogs. It is important to realise from the outset that your safety is of particular importance. When administering drugs to aggressive patients, care should be taken to prevent the dog from attacking you. More importantly however it should be ensured that the dog does not attack the owner. This consequence may have legal implications for the veterinarian. Intramuscular drugs are preferably administered by a poll syringe from a distance or a dart gun may be used. If dogs can be restrained manually, intravenous access may be readily obtained and drugs may be administered intravenously.</p>
<p align="justify">My technique for aggressive dogs that can be manually restrained is to obtain intravenous access in either the cephalic or the saphenus vein. This is followed by the intravenous administration of thiopentone in healthy dogs, endotracheal intubation and the administration of halothane. This option is usually only available in dogs that have been well trained.</p>
<p><strong>
<p>Acetylpromazine</p>
</strong></p>
<p align="justify">Many veterinarians use acetylpromazine to sedate aggressive dogs. Very often tablets are given to owners to administer to the dog at home before bringing it to the consulting room. Although this has been successful in many cases this practice is ill-advised. Acetylpromazine is a tranquilliser and as such has a ceiling sedative effect. Clinically this means that sedation increases to a point beyond which no increase is clinically seen. Acetylpromazine is also an anxiolytic. Anxious dogs may be prevented from biting by the administration of acetylpromazine. Increasing doses of acetylpromazine cause the dog to become collapsed due to hypotension. Any increase in adrenergic tone will briefly reverse the hypotension giving the dog enough strength to bite someone. But more importantly, acetylpromazine may make aggressive dogs even more aggressive by the removal of fear. There are reports in the literature of this effect and hence acetylpromazine should be avoided in aggressive animals. If a veterinarian were to prescribe acetylpromazine to an aggressive dog and the dog was to bite the owner then there may very well be legal ramifications as this effect has been documented.</p>
<p align="justify">The sedative effects of acetylpromazine can be increased by combining acetylpromazine with opioids (a neurolept combination). Appropriate opioids that can be used include morphine, fentanyl and buprenorphine. Buprenorphine takes approximately 30 minutes to reach its peak effect and hence should be given in advance. After the administration of a neurolept combination the animals should be allowed to quietly rest until the drugs have exerted full effect. Neuroleptic combinations may even be administered intramuscularly or intravenously.</p>
<p><strong>
<p>Alpha<sub>2</sub> Agonists</p>
</strong></p>
<p align="justify">The alpha<sub>2</sub> agonists are potent sedatives in small animals. The alpha<sub>2</sub> agonists are known to cause cardiovascular disturbances. The cardiovascular disturbances include an initial hypertension followed by slowing of the heart rate (bradycardia), SA and AV blocks, and a reduction in cardiac output. These cardiovascular changes may be detrimental in a compromised patient. Respiratory depression is also evident after the administration of these drugs. The intramuscular administration of the alpha<sub>2</sub> agonists will usually result in good sedation. That is provided the animal is allowed to relax in a stress free environment after the administration of the alpha<sub>2</sub> agonist. Failure to do this resulted inadequate sedation. Some dogs may still respond to painful stimuli and stress with an aggressive reaction after the administration of an alpha<sub>2</sub> agonist alone. The sedative action of alpha<sub>2</sub> agonist can be increased by the administration of an opioid, similar to that of the neuroleptic combination. If anaesthesia is to be induced after the administration of an alpha<sub>2</sub> agonist the dose of the anaesthetic agent should be carefully titrated to effect to avoid an accidental overdose. All the alpha<sub>2</sub> agonists are reversible bringing an element of safety.</p>
<p align="justify">As an alternative, alpha<sub>2</sub> agonists can be administered with ketamine intramuscularly to induce anesthesia. Such a combination can be administered through a pole syringe. An additional dose of thiopentone or propofol may be required for the endotracheal intubation.</p>
<p align="justify">Alpha<sub>2</sub> agonists may also be administered orally. The drug should be administered preferably sublingually as rapid absorption takes place. The dose of alpha<sub>2</sub> agonist needs to be increased by two to fourfold for an optimal effect. Again the patient needs to be left in a quiet stress free environment for approximately 30 minutes before it is handled.</p>
<p align="justify">Alpha<sub>2</sub> agonists have been successfully used subcutaneously in animals. The subcutaneous administration may be more easily accomplished. Again sufficient time must be allowed for the drug to take effect before the animal is handled.</p>
<p><strong>
<p>Zolazepam/Tiletamine</p>
</strong></p>
<p align="justify">This is another useful combination for aggressive dogs. The drug may be administered intramuscularly to produce profound sedation or anaesthesia for 30 – 60 minutes. The drug combination may also be administered orally to animals in a small quantity of food or sprayed into the mouth. The patient should then be allowed to become sedated in a quiet stress free environment. The cardiovascular stability of this drug combination is good.</p>
<p><strong>
<p>Pentobarbitone</p>
</strong></p>
<p>Pentobarbitone can be administered orally to animals. The dose required is quite large, between 40 and 80 mg/kg. The time for this drug to achieve its full effect may be well over an hour.</p>
<p align="center"> </p>
<table border="1" cellspacing="3" cellpadding="7" width="328">
<tbody>
<tr>
<td width="61%" valign="top">
<p><strong>Drugs</strong></p>
</td>
<td width="39%" valign="top"><strong> </strong>
<p><strong>Dose Rate </strong></p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Acetylpromazine</p>
</td>
<td width="39%" valign="top">
<p>0.01 – 0.5 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Buprenorphine</p>
</td>
<td width="39%" valign="top">
<p>0.01 – 0.03 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Ketamine</p>
</td>
<td width="39%" valign="top">
<p>10 – 30 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Medetomidine</p>
</td>
<td width="39%" valign="top">
<p>0.01 – 0.1 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Morphine</p>
</td>
<td width="39%" valign="top">
<p>0.1 – 1 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Pentobarbitone</p>
</td>
<td width="39%" valign="top">
<p>10 – 80 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Xylazine</p>
</td>
<td width="39%" valign="top">
<p>0.5 – 1 mg/kg</p>
</td>
</tr>
<tr>
<td width="61%" valign="top">
<p>Zolazepam/tiletamine</p>
</td>
<td width="39%" valign="top">
<p>0.5 – 1 mg/kg</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="center">Table 1: Drugs Dose rates. The following are suggested drug dose rates. Routes of administration and the clinical condition need to be considered when administering these agents. 1.</p>
<p>References</p>
</strong>1.Anash, O. B., Raekallio, M. and Vainio, O. 1998 Comparison of three doses of dexmedetomidine with medetomidine in cats following intramuscular administration. <em>Journal of Veterinary Pharmacology and Therapeutics</em> 21: 380 - 387.</p>
<p>2.Bergström, K. 1988 Cardiovascular and pulmonary effects of a new sedative/analgesic (medetomidine) as a preanaesthetic drug in the dog. <em>Acta Veterinaria Scandanavia</em> 29: 109 - 116.</p>
<p>3. Collard, J. A. 1958 Unusual reaction to chlorpromazine hydrochloride in a bitch. <em>Australian Veterinary Journal</em> 34: 90.</p>
<p>4.Dohoo, S. E., O'Connor, M. K., McDonell, W. N. and Dohoo, I. R. 1986 A clinical comparison of oxymorphone / acepromazine and fentanyl / droperidol sedation in dogs. <em>Journal of the American Animal Hospital Association</em> 22: 313 - 317.</p>
<p>5.Farver, T. B., Haskins, S. C. and Patz, J. D. 1986 Cardiopulmonary effects of acepromazine and of the subsequent administration of ketamine in the dog. <em>American Journal of Veterinary Research</em> 47: 3: 631 - 635.</p>
<p>6.Grimm, J. B., Grimm, K. A., Kneller, S. K., Tranquilli, W. J., Crochik, S. S., Bischoff, M. G. and Podolski, J. L. 2001 The effect of a combination of medetomidine-butorphanol and medetomidine, butorphanol, atropine on glomerular filtration rate in dogs. <em>Veterinary Radiology and Ultrasound</em> 42: 5: 458 - 462.</p>
<p>7.Hamlin, R. L. and Bednarski, L. M. 1989 Studies to determine the optimal dose of medetomidine in dogs. <em>Acta Veterinaria Scandanavia</em> 85: 89 - 95.</p>
<p>8. Hatch, R. C., Clark, J. D., Booth, N. H. and Kitzman, J. V. 1983 Comparison of five preanesthetic medicaments in pentobarbital-anesthetized dogs: antagonism by 4-aminopyridine, yohimbine, and naloxone. <em>American Journal of Veterinary Research</em> 44: 12: 2312 - 2319.</p>
<p>9. Hellyer, P., Muir, W. W., Hubbell, J. A. E. and Sally, J. 1988 Cardiorespiratory effects of the intravenous administration of tiletamine - zolazepam to cats. <em>Veterinary Surgery</em> 17: 2: 105 - 110.</p>
<p>10. Hellyer, P., Muir, W. W., Hubbell, J. A. E. and Sally, J. 1989 Cardiorespiratoy effects of the intravenous administration of tiletamine - zolazepam to dogs. <em>Veterinary Surgery</em> 18: 2: 160 - 165.</p>
<p>11. Klide, A. M., Calderwood, H. W. and Soma, L. R. 1975 Cardiopulmonary effects of xylazine in dogs. <em>American Journal of Veterinary Research</em> 36: 7: 931 - 935.</p>
<p>12. Ko, J. C. H., Bailey, J. E., Pablo, L. S. and Heaton-Jones, T. G. 1996 Comparison of sedative and cardiorespiratory effects of medetomidine and medetomidine-butorphanol combination in dogs. <em>American Journal of Veterinary Research</em> 57: 4: 535 - 540.</p>
<p>13. Ko, J. C. H., Fox, S. M. and Mandsager, R. E. 2000 Sedative and cardiorespiratory effects of medetomidine, medetomidne-butorphanol, and medetomidine-ketamine in dogs. <em>Journal of the American Veterinary Medical Association</em> 216: 10: 1578 - 1583.</p>
<p>14. Lamont, L. A., Bulmer, B. J., Grimm, K. A., Tranquilli, W. J. and Sisson, D. D. 2001 Cardiopulmonary evaluation of the use of medetomidine hydrochloride in cats. <em>American Journal of Veterinary Research</em> 62: 11: 1745 - 1749.</p>
<p>15. Meyer, E. K. 1997 Rare idiosyncratic reaction to acepromazine in dogs. <em>Journal of the American Veterinary Medical Association</em> 210: 8: 1114 - 1115.</p>
<p>16. Moens, Y. and Fargetton, X. 1990 A comparative studt of medetomidine/ketamine and xylazine/ketamine in dogs. <em>Veterinary Record</em> 127: 567 - 571.</p>
<p>17. Raiha, M. P., Raiha, J. and Short, C. E. 1989 A comparison of xylazine, acepromazine, meperidine and medetomidine as preanesthetics to halothane anesthesia in dogs. <em>Acta Veterinaria Scandanavia</em> 85: 97 - 102.</p>
<p>18. Ramsay, E. C. and Wetzel, R. W. 1998 Comparison of five regimens for oral administration of medication to induce sedation in dogs prior to euthanasia. <em>Journal of the American Veterinary Medical Association</em> 213: 2: 240 - 242.</p>
<p>19. Robertson, S. A., Hauptman, J. G., Nachreiner, R. F. and Richter, M. A. 2001 Effects of acetylpromazine or morphine on urine production in halothane-anesthetized dogs. <em>American Journal of Veterinary Research</em> 62: 12: 1922 - 1927.</p>
<p>20. Robinson, K. J., Jones, R. S. and Cripps, P. J. 2001 Effects of medetomidine and buprenorphine administered for sedation in dogs. <em>Journal of Small Animal Practice</em> 42: 444 - 447.</p>
<p>21. Vickery, R. G., Sheridan, B. C., Segal, I. S. and Maze, M. 1988 Anesthetic and hemodynamic effects of the sterioisomers of medetomidine, an <sub>2</sub>-adrenergic agonist, in halothane-anesthetized dogs. <em>Anesthesia and Analgesia</em> 67: 611 - 615.</p>
<p>22. Waechter, R. A. 1982 Unusual reaction to acepromazine maleate in the dog. <em>Journal of the American Veterinary Medical Association</em> 180: 1: 73 - 74.</p>
<p>23.Wetzel, R. W. and Ramsay, E. C. 1998 Comparison of four regimens for intraoral administration of medication to induce sedation in cats prior to euthanazia. <em>Journal of the American Veterinary Medical Association</em> 213: 2: 243 - 245.</p>
<p><em>(Published - April 2003, courtesy of Dr K E Joubert)</em></p>
<p> </p></div>Guidelines - Dealing With Aggressive Canine Patients2009-09-02T10:41:40+00:002009-09-02T10:41:40+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/236-guidelines-dealing-with-aggressive-canine-patientsAdministratorwebmaster@savc.org.za<div class="feed-description"><p><strong>
<p align="center">DEALING WITH AGGRESSIVE CANINE PATIENTS</p>
</strong></p>
<p align="center">Compiled by Dr Q Sonntag and peer reviewed by Dr H Zulch</p>
<p><strong><em>
<p align="justify">A behavioural perspective</p>
</em>
<p align="justify">Introduction</p>
</strong></p>
<p align="justify">Canine aggression is a common occurrence in veterinary practices. It often results in injury to veterinarians and / or staff members. Most injuries sustained by veterinarians and staff members in this way are caused by a lack of knowledge of canine signalling and communication. A better understanding of these issues, as well as of fear-related aggression, can prevent unnecessary injuries caused by aggressive patients.</p>
<p><strong>
<p align="justify">What is fear?</p>
</strong></p>
<p align="justify">In most cases where dogs bite veterinarians, they do so as a result of fear. Pain is a very powerful elicitor of fear. Dogs in the veterinary consulting room often experience pain. Fear is the response shown by an animal when it perceives a threat to its own safety. An unfamiliar environment and strange people are often perceived as threats by dogs. Fear is a reaction to a stressful, dangerous situation. Fear also involves a certain emotion - a feeling of apprehension associated with the fear-evoking stimulus.</p>
<p align="justify">Fear can be expressed in different ways by animals:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Freezing: This usually occurs when the threat is of low intensity or distant (inhibitory response).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Fleeing: This is a response to high levels of fear or a threat that is very close (excitatory response).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Fighting: This response occurs in the presence of high intensity fear and when the animal is unable to flee (excitatory response). Fleeing is often blocked by the presence of the threat itself.</td>
</tr>
</tbody>
</table>
<p align="justify">The most common fear-eliciting stimuli in dogs and cats are loud noises, unfamiliar people, unfamiliar animals and novel situations. Fear can be an innate response or a learned behaviour, and is often a combination of both.</p>
<p align="justify">Fear can be recognised by certain physiological changes as well as body and facial signalling (visual signals) .</p>
<p align="justify">Physiological signs or fear are</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Hyperpnoea (panting)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Tachycardia</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Mydriasis</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Increased viscosity of saliva and decreased salivation</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Muscle tremors, shivering, muscle tension</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Restlessness</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Urination (intense fear)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Defaecation (intense fear)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Anal sac expression (intense fear)</td>
</tr>
</tbody>
</table>
<p align="justify">Visual signs of fear are:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Lowering of the body and head</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Piloerection (raised hackles)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Tail tucked between the legs</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Averting the gaze (avoiding eye contact)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ears flattened</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Corners of mouth retracted</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Mouth open, exposing all teeth</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Vocalisation (whining, high-pitched barking)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Snarling, growling, snapping</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">Fear and anxiety</p>
</strong></p>
<p align="justify">Fear is an acute, adaptive response to a specific situation that is potentially injurious to the animal. Anxiety is a chronic state of sympathetic arousal in response to an expected threat which may or may not be real. Anxious dogs appear tense and are hypervigilant (constantly alert, scanning the environment for potential threats). Chronic anxiety often gives rise to behavioural problems including generalised fears and phobias, unpredictable aggression and compulsive behaviour.</p>
<p><strong>
<p align="justify">Fear and aggression</p>
</strong></p>
<p align="justify">When a dog perceives a threat that is in close proximity and from which it cannot escape, it will use certain signals in an attempt to increase the distance between it and the threat. Raised hackles, snarling and growling are all distance-increasing signals and are meant to make the threat go away (see Table 1). If this does not happen and the threat continues to approach or does not go away, the next (and only, from the dog’s perspective) option for the dog is to inflict injury by biting.</p>
<p align="justify">The typical consulting room scenario is the dog that finds itself in a strange environment with a strange person. It feels insecure and threatened, tries to jump off the table or escape through the door, is restrained and now effectively can no longer escape the impending threat to its safety. As its critical space is invaded, whether by the physical restraint, being touched all over the body during the examination or having a thermometer inserted, it responds with a warning such as a growl. The examination continues regardless. In some instances, such behaviour is punished with verbal reprimands, further physical restraint or sometimes even physical punishment such as being slapped.</p>
<p align="justify">The dog’s suspicion that this person may be a threat is now confirmed, especially in the situation where physical correction is applied. Once the possible threat is perceived to be a real threat, the dog has no other option than to respond by biting in defense of its own safety.</p>
<p align="justify">A similar situation occurs in the hospital cage. The fearful dog may not allow anyone to touch it because it perceives the approach as a threat to its safety. The more the handler insists on getting closer, the more threatened the dog feels and the more it is likely to react aggressively.</p>
<p align="justify">The veterinarian or handler often reacts to this reflexively by hitting the dog – again a confirmation to the dog that this person is indeed dangerous and thus ample justification, from the dog’s point of view, to escalate the aggressive behaviour. This escalation of aggression may be evident immediately, or at a future visit.</p>
<p><strong>
<p align="justify">Learned fear and aggression</p>
</strong></p>
<p align="justify">Dogs can therefore learn to be aggressive to vets because vets often reinforce the notion that they are to be feared by the manner in which they respond to canine fear. Another situation which also often occurs, is that of the owner inadvertently reinforcing fearful and aggressive behaviour by comforting a dog that is growling in the consulting room. It is a perfectly natural human response to do this and clients need to be made aware of the effect this has. The more attention is paid by the client to fearful and aggressive behaviour, the more the undesired behaviour is reinforced. The dog learns that it is appropriate to behave in such a way as it is being rewarded by the owner.</p>
<p><strong>
<p align="justify">Prevention of fear-related aggression in the veterinary practice (table 1)</p>
</strong></p>
<p align="justify">At the age of 3 – 16 weeks, puppies are most sensitive to influences from their environment. This is commonly known as the "socialisation period". If they have positive experiences with all the environmental stimuli they may encounter later in their lives (cars, vets, people of different appearances, noises, other dogs, other animals etc) during this period, they are less likely to view these stimuli as dangerous or threatening later in their lives.</p>
<p align="justify">If however, during this sensitive age period, they have negative experiences, they learn by association that those situations which are unpleasant or have negative consequences for them, are potentially dangerous.</p>
<p align="justify">Veterinarians can play an active role in assisting clients to produce happy, confident dogs by encouraging them to expose their puppies in a positive way to as many environmental stimuli as possible before they are 6 months old.</p>
<p align="justify">The veterinarian must ensure that the first experience a puppy has in a veterinary practice is pleasant:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Encourage a no-charge pre-vaccination visit where the vet and veterinary staff play with the puppy and feed it delicious treats (the treats do not need to be big, just tasty).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">When the puppy does have to receive an injection, take special care to minimise the chances that the puppy will feel pain: Use new, sharp needles and precede the injection with positive, fun interaction. Desensitise the injection site by rubbing it fairly vigourously before injecting.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Distract the puppy during the injection or other potentially painful procedure with an interesting toy.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Reward the puppy immediately afterwards with a tasty treat if it behaved well.</td>
</tr>
</tbody>
</table>
<p align="justify">Encourage owners of new patients, especially puppies, to visit the practice often with the dog when there is no need for a consultation, and to feed treats during such visits or provide other positive experiences such as play and presentation of favourite toys.</p>
<p align="justify">Make an effort to invite clients and pets into the consulting room during such visits, simply to show the dog that the consulting room does not always mean unpleasant things. Put the puppy on the table and pet it and give it a treat. Such visits can play an important role in establishing a healthy and mutually beneficial client-veterinarian relationship.</p>
<p align="justify">Veterinary practices can offer puppy socialisation classes or once-off puppy parties on their premises to help the puppies make a positive association with the veterinary practice. At the end of each class, the puppies are taken through the consulting room where they can be handled and given treats.</p>
<p align="justify">The veterinarian or veterinary staff should explain to clients how their own behaviour can inadvertently reinforce unacceptable canine behaviour. Most people do not understand this concept but fully understand the implications of their actions once it is explained to them in a caring manner. Clients who understand that attention given to a fearful or aggressive dog is in fact positive reinforcement for such behaviour, will take care to change their own behaviour. The client needs to withdraw all physical and verbal interaction with the dog the instant it shows inappropriate behaviour.</p>
<table border="1" cellspacing="1" cellpadding="7" width="614">
<tbody>
<tr>
<td valign="top">
<p align="justify">First visit – no procedures, no pain, just fun</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Take care with first injection – new needle; gentle handling</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Reward puppy with treats</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Distract puppy with fun toy during any potentially painful procedure</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Encourage regular visits in between consultations</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Invite client and puppy into consulting room just for fun and pleasant experience</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Offer puppy socialisation classes, or once-off puppy parties</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Educate clients on how to behave when the patient shows signs of fear and aggression</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">Table 1: Preventing fear-related aggression in the veterinary practice</p>
<p align="justify">Recommendations for dealing with aggressive dogs in the veterinary practice</p>
</strong></p>
<p align="justify">Dogs that already perceive the veterinarian and / or veterinary staff as a threat need to be handled with care and patience. The person handling the dog should act calmly and in a non-threatening manner, using calming signals to relax the dog.</p>
<p align="justify">Calming signals are visual, physical signals (body language) which dogs use in order to avoid conflict. This can be observed when dogs unfamiliar with each other meet and wish to convey to each other that they do not intend an antagonistic interaction. People can use many of these signals to show a dog that they do not wish to engage in conflict (see table 2).</p>
<table border="1" cellspacing="1" cellpadding="7" width="614">
<tbody>
<tr>
<td valign="top">
<p align="justify">Avoiding direct eye contact</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Turning the head away</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Turning the body sideways</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Keeping the body low – crouching, sitting down</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Approaching the dog from the side</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Approaching very slowly</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Avoiding rapid movements</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">Table 2: Calming signals which can be used by the veterinarian to calm a fearful dog</p>
</strong></p>
<p align="justify">The veterinarian can effectively use calming signals to signal to a fearful dog that conflict is not intended and that there is therefore not a real threat.</p>
<p align="justify">A slow, calm approach without any threatening body language will help a fearful dog relax. The veterinarian should make a point of avoiding direct eye contact with the dog, approaching the dog from the side with a sideways body posture, avoiding rapid movements and even yawning and licking the lips. A tasty treat can be offered in a slowly outstretched hand while not looking at the dog directly. If the dog refuses this, a treat can be tossed on the ground first. However, highly stressed dogs often do not eat at all. Time and patience, and possibly sedation will be required.</p>
<p align="justify">Touching the dog should be postponed until the dog shows trust by eating from the veterinarian’s hand or sniffing and approaching the vet in a calm manner. Very fearful dogs are best examined and treated on the floor rather than on the examination table. Picking up a dog and placing it on a table may be perceived as a threat and exacerbate its fear.</p>
<p align="justify">A calm relaxed approach by the veterinarian makes the dog and the client relax and proves to the dog that the perceived threat is not real.</p>
<p align="justify">The same approach should be used when retrieving a fearfully aggressive dog from a hospital cage.</p>
<p><strong>
<p align="justify">The role of physical punishment and force</p>
</strong></p>
<p align="justify">Physical punishment, jerking the dog on a choke chain and shouting are counterproductive. The veterinarian should avoid such actions as they will only result in heightened fear and / or aggression.</p>
<p align="justify">Retaliating to aggression with aggression results in a vicious spiral of increasing aggression and anxiety with no benefit to anybody.</p>
<p align="justify">Physical abuse of patients (strangling, beating, helicoptering, long-term muzzling) cannot be justified and will place the veterinarian at risk of being charged with unprofessional conduct and / or animal cruelty.</p>
<p><strong>
<p align="justify">The use of muzzles</p>
</strong></p>
<p align="justify">The veterinarian who deals with a fearful or aggressive dog should consider the well-being of the animal and also his or her own safety, as well as that of the client. If a dog is not approachable at all and does not respond favourably to calming signals, the veterinarian should use appropriate methods of restraint. Acceptable methods of restraint would include the use of muzzles and / or pharmacological restraint.</p>
<p align="justify">When in doubt, veterinarians are advised to use muzzles to protect themselves and the clients. The veterinarian should make this decision and need not be led by a client insisting that the "dog won’t bite" – in an unfamiliar context, there is no guarantee that a dog will not bite. It is not reasonable for the client to expect the veterinarian to place him- or herself at risk.</p>
<p align="justify">Tight-fitting nylon muzzles can only be used for short periods of time (a few minutes) as they restrict panting and thereby affect thermoregulation. They require close contact with the dog’s muzzle to be put on and with an extremely reactive dog this could be risky. Crepe bandage (improvised) muzzles also restrict panting but are easier to apply without getting the hands close to the mouth of the dog.</p>
<p align="justify">Basket-type muzzles allow panting and usually even eating and drinking and can be left on for longer periods of time. However, a dog should always be under direct supervision and on a lead when wearing any type of muzzle. Dogs should never be placed unsupervised in a kennel with a muzzle on.</p>
<p align="justify">If a dog has a history of aggressive behaviour in the consulting room, it is advisable to request the client to put on a muzzle before entering the veterinary practice. The calmer the dog is when the muzzle is put on, the better.</p>
<p align="justify">If the dog is already in the consulting room when the muzzle needs to be used, the veterinarian must use his or her discretion in deciding who should put it on. If the client is unsure or incapable, it is better for the vet to do it.</p>
<p><strong>
<p align="justify">Dogs with a known history of aggression</p>
</strong></p>
<p align="justify">Dogs that have a known history of aggression in the veterinary practice should be identified on the patient record and a course of action in handling such patients should be decided upon together with the client:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Clients could be requested to acquire a muzzle and get the dog used to it at home so that the muzzle does not contribute to the stress of visiting the practice.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Dogs could be premedicated with anxiolytic medication before visiting the practice. The longer-acting benzodiazepines like oxazepam (0,2 - 1 mg/kg) or alprazolam (0,125 – 1 mg/kg not exceeding 4 mg/dog) are recommended.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Clients could be referred to a veterinary behaviour practitioner for an objective assessment and appropriate therapeutic approach.</td>
</tr>
</tbody>
</table>
<p align="justify">Veterinarians understandably become frustrated with uncooperative, aggressive patients and then often blame the clients for having uncontrollable pets. However, an accusatory attitude towards the client simply alienates the client and certainly does not help the dog. A positive and empathetic approach to address the problem will prevent the breakdown of the veterinarian-client relationship.</p>
<p><strong>
<p align="justify">Right of refusal of treatment</p>
</strong></p>
<p align="justify">The veterinarian is entitled to refuse examination and treatment of an extremely aggressive dog. Such cases could be referred to another veterinarian with the agreement of such veterinarian, or the client can be requested to return with the dog at another time, when specific measures can be taken (e.g. prior application of a muzzle or administration of medication).</p>
<p align="justify">In the event of an aggressive dog that cannot be controlled at all even if all reasonable measures have been taken, the veterinarian has the right to refuse seeing that patient.</p>
<p><strong>
<p align="justify">Hospitalisation of aggressive dogs</p>
</strong></p>
<p align="justify">When an aggressive dog needs to be hospitalised and the veterinarian is unable to provide the necessary care and treatment due to its aggression, the owner, or somebody appointed by the owner with whom the dog is familiar, should be requested to assist in removing the dog from its hospital cage and administering the necessary treatment.</p>
<p><strong>
<p align="justify">Safety and security</p>
</strong></p>
<p align="justify">The veterinarian never needs to place him- or herself at risk of being injured. Veterinarians are often injured in the process of preventing patients from escaping. Precautions should be taken to ensure that dogs cannot escape from the practice should they become uncontrollable. Such precautions would include, amongst others, secure gates on cages, secure doors to hospital rooms and consulting rooms, safe outside perimeters of practices and escape-proof windows.</p>
<p align="justify">Clients should be encouraged to use proper leads and collars so that dogs cannot escape and place veterinarians and veterinary staff at risk by having to chase and catch such animals. If the veterinarian takes reasonable precautions to prevent escape of animals, it will not be necessary to risk being bitten while retrieving an escaped dog.</p>
<p><strong>
<p align="justify">Dominance aggression – fact and fiction</p>
</strong></p>
<p align="justify">There is a misconception that dogs bite vets because they want to exert dominance. Dominance aggression, however, is a problem of resource control within the dog’s social structure in its home. It typically occurs in the dog’s own territory – it is usually directed to people familiar to the dog who are part of the dog’s social system. The aggression is an attempt by the dog to control access to resources. Aggression directed towards people unfamiliar to the dog, like the vet, has to do with a direct threat to the animal’s safety and is the result of fear.</p>
<p><strong>
<p align="justify">Conclusion</p>
</strong></p>
<p align="justify">Veterinarians can play a pro-active role in minimising aggressive interaction with patients. Clients appreciate such efforts as it confirms that the veterinarian really does care about the patient. This will result in a more positive vet-client relationship with all the ensuing benefits.</p>
<p align="justify">References</p>
<ol>
<li>Abrantes, Roger 1997 Dog Language: An encyclopaedia of canine behaviour</li>
<li>Wakan Tanka Publishers, Naperville, Illinois, USA</li>
<li>Lindsay, Steven R 2001 <em>Handbook of applied dog behaviour and training, Volume 1</em> Iowa State University Press</li>
<li>Lindsay, Steven R 2001 <em>Handbook of applied dog behaviour and training, Volume 2</em> Iowa State University Press</li>
<li>Overall, Karen L 1997 <em>Clinial behavioral medicine for small animals </em>Mosby</li>
<li>Rugaas, Turid 1997 <em>On talking terms with dogs: Calming signals </em>Legacy By Mail, Inc, Carlsborg, USA</li>
</ol>
<p><em>(Published- April 2003, courtesy of Dr I Sonntag)</em></p>
<p> </p></div><div class="feed-description"><p><strong>
<p align="center">DEALING WITH AGGRESSIVE CANINE PATIENTS</p>
</strong></p>
<p align="center">Compiled by Dr Q Sonntag and peer reviewed by Dr H Zulch</p>
<p><strong><em>
<p align="justify">A behavioural perspective</p>
</em>
<p align="justify">Introduction</p>
</strong></p>
<p align="justify">Canine aggression is a common occurrence in veterinary practices. It often results in injury to veterinarians and / or staff members. Most injuries sustained by veterinarians and staff members in this way are caused by a lack of knowledge of canine signalling and communication. A better understanding of these issues, as well as of fear-related aggression, can prevent unnecessary injuries caused by aggressive patients.</p>
<p><strong>
<p align="justify">What is fear?</p>
</strong></p>
<p align="justify">In most cases where dogs bite veterinarians, they do so as a result of fear. Pain is a very powerful elicitor of fear. Dogs in the veterinary consulting room often experience pain. Fear is the response shown by an animal when it perceives a threat to its own safety. An unfamiliar environment and strange people are often perceived as threats by dogs. Fear is a reaction to a stressful, dangerous situation. Fear also involves a certain emotion - a feeling of apprehension associated with the fear-evoking stimulus.</p>
<p align="justify">Fear can be expressed in different ways by animals:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Freezing: This usually occurs when the threat is of low intensity or distant (inhibitory response).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Fleeing: This is a response to high levels of fear or a threat that is very close (excitatory response).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Fighting: This response occurs in the presence of high intensity fear and when the animal is unable to flee (excitatory response). Fleeing is often blocked by the presence of the threat itself.</td>
</tr>
</tbody>
</table>
<p align="justify">The most common fear-eliciting stimuli in dogs and cats are loud noises, unfamiliar people, unfamiliar animals and novel situations. Fear can be an innate response or a learned behaviour, and is often a combination of both.</p>
<p align="justify">Fear can be recognised by certain physiological changes as well as body and facial signalling (visual signals) .</p>
<p align="justify">Physiological signs or fear are</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Hyperpnoea (panting)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Tachycardia</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Mydriasis</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Increased viscosity of saliva and decreased salivation</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Muscle tremors, shivering, muscle tension</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Restlessness</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Urination (intense fear)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Defaecation (intense fear)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Anal sac expression (intense fear)</td>
</tr>
</tbody>
</table>
<p align="justify">Visual signs of fear are:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Lowering of the body and head</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Piloerection (raised hackles)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Tail tucked between the legs</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Averting the gaze (avoiding eye contact)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ears flattened</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Corners of mouth retracted</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Mouth open, exposing all teeth</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Vocalisation (whining, high-pitched barking)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Snarling, growling, snapping</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">Fear and anxiety</p>
</strong></p>
<p align="justify">Fear is an acute, adaptive response to a specific situation that is potentially injurious to the animal. Anxiety is a chronic state of sympathetic arousal in response to an expected threat which may or may not be real. Anxious dogs appear tense and are hypervigilant (constantly alert, scanning the environment for potential threats). Chronic anxiety often gives rise to behavioural problems including generalised fears and phobias, unpredictable aggression and compulsive behaviour.</p>
<p><strong>
<p align="justify">Fear and aggression</p>
</strong></p>
<p align="justify">When a dog perceives a threat that is in close proximity and from which it cannot escape, it will use certain signals in an attempt to increase the distance between it and the threat. Raised hackles, snarling and growling are all distance-increasing signals and are meant to make the threat go away (see Table 1). If this does not happen and the threat continues to approach or does not go away, the next (and only, from the dog’s perspective) option for the dog is to inflict injury by biting.</p>
<p align="justify">The typical consulting room scenario is the dog that finds itself in a strange environment with a strange person. It feels insecure and threatened, tries to jump off the table or escape through the door, is restrained and now effectively can no longer escape the impending threat to its safety. As its critical space is invaded, whether by the physical restraint, being touched all over the body during the examination or having a thermometer inserted, it responds with a warning such as a growl. The examination continues regardless. In some instances, such behaviour is punished with verbal reprimands, further physical restraint or sometimes even physical punishment such as being slapped.</p>
<p align="justify">The dog’s suspicion that this person may be a threat is now confirmed, especially in the situation where physical correction is applied. Once the possible threat is perceived to be a real threat, the dog has no other option than to respond by biting in defense of its own safety.</p>
<p align="justify">A similar situation occurs in the hospital cage. The fearful dog may not allow anyone to touch it because it perceives the approach as a threat to its safety. The more the handler insists on getting closer, the more threatened the dog feels and the more it is likely to react aggressively.</p>
<p align="justify">The veterinarian or handler often reacts to this reflexively by hitting the dog – again a confirmation to the dog that this person is indeed dangerous and thus ample justification, from the dog’s point of view, to escalate the aggressive behaviour. This escalation of aggression may be evident immediately, or at a future visit.</p>
<p><strong>
<p align="justify">Learned fear and aggression</p>
</strong></p>
<p align="justify">Dogs can therefore learn to be aggressive to vets because vets often reinforce the notion that they are to be feared by the manner in which they respond to canine fear. Another situation which also often occurs, is that of the owner inadvertently reinforcing fearful and aggressive behaviour by comforting a dog that is growling in the consulting room. It is a perfectly natural human response to do this and clients need to be made aware of the effect this has. The more attention is paid by the client to fearful and aggressive behaviour, the more the undesired behaviour is reinforced. The dog learns that it is appropriate to behave in such a way as it is being rewarded by the owner.</p>
<p><strong>
<p align="justify">Prevention of fear-related aggression in the veterinary practice (table 1)</p>
</strong></p>
<p align="justify">At the age of 3 – 16 weeks, puppies are most sensitive to influences from their environment. This is commonly known as the "socialisation period". If they have positive experiences with all the environmental stimuli they may encounter later in their lives (cars, vets, people of different appearances, noises, other dogs, other animals etc) during this period, they are less likely to view these stimuli as dangerous or threatening later in their lives.</p>
<p align="justify">If however, during this sensitive age period, they have negative experiences, they learn by association that those situations which are unpleasant or have negative consequences for them, are potentially dangerous.</p>
<p align="justify">Veterinarians can play an active role in assisting clients to produce happy, confident dogs by encouraging them to expose their puppies in a positive way to as many environmental stimuli as possible before they are 6 months old.</p>
<p align="justify">The veterinarian must ensure that the first experience a puppy has in a veterinary practice is pleasant:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Encourage a no-charge pre-vaccination visit where the vet and veterinary staff play with the puppy and feed it delicious treats (the treats do not need to be big, just tasty).</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">When the puppy does have to receive an injection, take special care to minimise the chances that the puppy will feel pain: Use new, sharp needles and precede the injection with positive, fun interaction. Desensitise the injection site by rubbing it fairly vigourously before injecting.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Distract the puppy during the injection or other potentially painful procedure with an interesting toy.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Reward the puppy immediately afterwards with a tasty treat if it behaved well.</td>
</tr>
</tbody>
</table>
<p align="justify">Encourage owners of new patients, especially puppies, to visit the practice often with the dog when there is no need for a consultation, and to feed treats during such visits or provide other positive experiences such as play and presentation of favourite toys.</p>
<p align="justify">Make an effort to invite clients and pets into the consulting room during such visits, simply to show the dog that the consulting room does not always mean unpleasant things. Put the puppy on the table and pet it and give it a treat. Such visits can play an important role in establishing a healthy and mutually beneficial client-veterinarian relationship.</p>
<p align="justify">Veterinary practices can offer puppy socialisation classes or once-off puppy parties on their premises to help the puppies make a positive association with the veterinary practice. At the end of each class, the puppies are taken through the consulting room where they can be handled and given treats.</p>
<p align="justify">The veterinarian or veterinary staff should explain to clients how their own behaviour can inadvertently reinforce unacceptable canine behaviour. Most people do not understand this concept but fully understand the implications of their actions once it is explained to them in a caring manner. Clients who understand that attention given to a fearful or aggressive dog is in fact positive reinforcement for such behaviour, will take care to change their own behaviour. The client needs to withdraw all physical and verbal interaction with the dog the instant it shows inappropriate behaviour.</p>
<table border="1" cellspacing="1" cellpadding="7" width="614">
<tbody>
<tr>
<td valign="top">
<p align="justify">First visit – no procedures, no pain, just fun</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Take care with first injection – new needle; gentle handling</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Reward puppy with treats</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Distract puppy with fun toy during any potentially painful procedure</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Encourage regular visits in between consultations</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Invite client and puppy into consulting room just for fun and pleasant experience</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Offer puppy socialisation classes, or once-off puppy parties</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Educate clients on how to behave when the patient shows signs of fear and aggression</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">Table 1: Preventing fear-related aggression in the veterinary practice</p>
<p align="justify">Recommendations for dealing with aggressive dogs in the veterinary practice</p>
</strong></p>
<p align="justify">Dogs that already perceive the veterinarian and / or veterinary staff as a threat need to be handled with care and patience. The person handling the dog should act calmly and in a non-threatening manner, using calming signals to relax the dog.</p>
<p align="justify">Calming signals are visual, physical signals (body language) which dogs use in order to avoid conflict. This can be observed when dogs unfamiliar with each other meet and wish to convey to each other that they do not intend an antagonistic interaction. People can use many of these signals to show a dog that they do not wish to engage in conflict (see table 2).</p>
<table border="1" cellspacing="1" cellpadding="7" width="614">
<tbody>
<tr>
<td valign="top">
<p align="justify">Avoiding direct eye contact</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Turning the head away</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Turning the body sideways</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Keeping the body low – crouching, sitting down</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Approaching the dog from the side</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Approaching very slowly</p>
</td>
</tr>
<tr>
<td valign="top">
<p align="justify">Avoiding rapid movements</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p align="justify">Table 2: Calming signals which can be used by the veterinarian to calm a fearful dog</p>
</strong></p>
<p align="justify">The veterinarian can effectively use calming signals to signal to a fearful dog that conflict is not intended and that there is therefore not a real threat.</p>
<p align="justify">A slow, calm approach without any threatening body language will help a fearful dog relax. The veterinarian should make a point of avoiding direct eye contact with the dog, approaching the dog from the side with a sideways body posture, avoiding rapid movements and even yawning and licking the lips. A tasty treat can be offered in a slowly outstretched hand while not looking at the dog directly. If the dog refuses this, a treat can be tossed on the ground first. However, highly stressed dogs often do not eat at all. Time and patience, and possibly sedation will be required.</p>
<p align="justify">Touching the dog should be postponed until the dog shows trust by eating from the veterinarian’s hand or sniffing and approaching the vet in a calm manner. Very fearful dogs are best examined and treated on the floor rather than on the examination table. Picking up a dog and placing it on a table may be perceived as a threat and exacerbate its fear.</p>
<p align="justify">A calm relaxed approach by the veterinarian makes the dog and the client relax and proves to the dog that the perceived threat is not real.</p>
<p align="justify">The same approach should be used when retrieving a fearfully aggressive dog from a hospital cage.</p>
<p><strong>
<p align="justify">The role of physical punishment and force</p>
</strong></p>
<p align="justify">Physical punishment, jerking the dog on a choke chain and shouting are counterproductive. The veterinarian should avoid such actions as they will only result in heightened fear and / or aggression.</p>
<p align="justify">Retaliating to aggression with aggression results in a vicious spiral of increasing aggression and anxiety with no benefit to anybody.</p>
<p align="justify">Physical abuse of patients (strangling, beating, helicoptering, long-term muzzling) cannot be justified and will place the veterinarian at risk of being charged with unprofessional conduct and / or animal cruelty.</p>
<p><strong>
<p align="justify">The use of muzzles</p>
</strong></p>
<p align="justify">The veterinarian who deals with a fearful or aggressive dog should consider the well-being of the animal and also his or her own safety, as well as that of the client. If a dog is not approachable at all and does not respond favourably to calming signals, the veterinarian should use appropriate methods of restraint. Acceptable methods of restraint would include the use of muzzles and / or pharmacological restraint.</p>
<p align="justify">When in doubt, veterinarians are advised to use muzzles to protect themselves and the clients. The veterinarian should make this decision and need not be led by a client insisting that the "dog won’t bite" – in an unfamiliar context, there is no guarantee that a dog will not bite. It is not reasonable for the client to expect the veterinarian to place him- or herself at risk.</p>
<p align="justify">Tight-fitting nylon muzzles can only be used for short periods of time (a few minutes) as they restrict panting and thereby affect thermoregulation. They require close contact with the dog’s muzzle to be put on and with an extremely reactive dog this could be risky. Crepe bandage (improvised) muzzles also restrict panting but are easier to apply without getting the hands close to the mouth of the dog.</p>
<p align="justify">Basket-type muzzles allow panting and usually even eating and drinking and can be left on for longer periods of time. However, a dog should always be under direct supervision and on a lead when wearing any type of muzzle. Dogs should never be placed unsupervised in a kennel with a muzzle on.</p>
<p align="justify">If a dog has a history of aggressive behaviour in the consulting room, it is advisable to request the client to put on a muzzle before entering the veterinary practice. The calmer the dog is when the muzzle is put on, the better.</p>
<p align="justify">If the dog is already in the consulting room when the muzzle needs to be used, the veterinarian must use his or her discretion in deciding who should put it on. If the client is unsure or incapable, it is better for the vet to do it.</p>
<p><strong>
<p align="justify">Dogs with a known history of aggression</p>
</strong></p>
<p align="justify">Dogs that have a known history of aggression in the veterinary practice should be identified on the patient record and a course of action in handling such patients should be decided upon together with the client:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Clients could be requested to acquire a muzzle and get the dog used to it at home so that the muzzle does not contribute to the stress of visiting the practice.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Dogs could be premedicated with anxiolytic medication before visiting the practice. The longer-acting benzodiazepines like oxazepam (0,2 - 1 mg/kg) or alprazolam (0,125 – 1 mg/kg not exceeding 4 mg/dog) are recommended.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Clients could be referred to a veterinary behaviour practitioner for an objective assessment and appropriate therapeutic approach.</td>
</tr>
</tbody>
</table>
<p align="justify">Veterinarians understandably become frustrated with uncooperative, aggressive patients and then often blame the clients for having uncontrollable pets. However, an accusatory attitude towards the client simply alienates the client and certainly does not help the dog. A positive and empathetic approach to address the problem will prevent the breakdown of the veterinarian-client relationship.</p>
<p><strong>
<p align="justify">Right of refusal of treatment</p>
</strong></p>
<p align="justify">The veterinarian is entitled to refuse examination and treatment of an extremely aggressive dog. Such cases could be referred to another veterinarian with the agreement of such veterinarian, or the client can be requested to return with the dog at another time, when specific measures can be taken (e.g. prior application of a muzzle or administration of medication).</p>
<p align="justify">In the event of an aggressive dog that cannot be controlled at all even if all reasonable measures have been taken, the veterinarian has the right to refuse seeing that patient.</p>
<p><strong>
<p align="justify">Hospitalisation of aggressive dogs</p>
</strong></p>
<p align="justify">When an aggressive dog needs to be hospitalised and the veterinarian is unable to provide the necessary care and treatment due to its aggression, the owner, or somebody appointed by the owner with whom the dog is familiar, should be requested to assist in removing the dog from its hospital cage and administering the necessary treatment.</p>
<p><strong>
<p align="justify">Safety and security</p>
</strong></p>
<p align="justify">The veterinarian never needs to place him- or herself at risk of being injured. Veterinarians are often injured in the process of preventing patients from escaping. Precautions should be taken to ensure that dogs cannot escape from the practice should they become uncontrollable. Such precautions would include, amongst others, secure gates on cages, secure doors to hospital rooms and consulting rooms, safe outside perimeters of practices and escape-proof windows.</p>
<p align="justify">Clients should be encouraged to use proper leads and collars so that dogs cannot escape and place veterinarians and veterinary staff at risk by having to chase and catch such animals. If the veterinarian takes reasonable precautions to prevent escape of animals, it will not be necessary to risk being bitten while retrieving an escaped dog.</p>
<p><strong>
<p align="justify">Dominance aggression – fact and fiction</p>
</strong></p>
<p align="justify">There is a misconception that dogs bite vets because they want to exert dominance. Dominance aggression, however, is a problem of resource control within the dog’s social structure in its home. It typically occurs in the dog’s own territory – it is usually directed to people familiar to the dog who are part of the dog’s social system. The aggression is an attempt by the dog to control access to resources. Aggression directed towards people unfamiliar to the dog, like the vet, has to do with a direct threat to the animal’s safety and is the result of fear.</p>
<p><strong>
<p align="justify">Conclusion</p>
</strong></p>
<p align="justify">Veterinarians can play a pro-active role in minimising aggressive interaction with patients. Clients appreciate such efforts as it confirms that the veterinarian really does care about the patient. This will result in a more positive vet-client relationship with all the ensuing benefits.</p>
<p align="justify">References</p>
<ol>
<li>Abrantes, Roger 1997 Dog Language: An encyclopaedia of canine behaviour</li>
<li>Wakan Tanka Publishers, Naperville, Illinois, USA</li>
<li>Lindsay, Steven R 2001 <em>Handbook of applied dog behaviour and training, Volume 1</em> Iowa State University Press</li>
<li>Lindsay, Steven R 2001 <em>Handbook of applied dog behaviour and training, Volume 2</em> Iowa State University Press</li>
<li>Overall, Karen L 1997 <em>Clinial behavioral medicine for small animals </em>Mosby</li>
<li>Rugaas, Turid 1997 <em>On talking terms with dogs: Calming signals </em>Legacy By Mail, Inc, Carlsborg, USA</li>
</ol>
<p><em>(Published- April 2003, courtesy of Dr I Sonntag)</em></p>
<p> </p></div>Guidelines - Performing & Possible Complications Of Ovariohysterectomy In The Bitch & Queen2009-09-02T10:37:52+00:002009-09-02T10:37:52+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/235-guidelines-performing-a-possible-complications-of-ovariohysterectomy-in-the-bitch-a-queenAdministratorwebmaster@savc.org.za<div class="feed-description"><p><strong>
<p align="center">GUIDELINES FOR PERFORMING &amp; POSSIBLE COMPLICATIONS OF OVARIOHYSTERECTOMY IN THE BITCH &amp; QUEEN</p>
</strong></p>
<p align="center">Compiled by Dr J.L. Möller BVSc(Hons), MMedVet(Chir)</p>
<p align="justify">Sterilisation of the bitch and queen by ovariohysterectomy should be one of the procedures that most veterinary practitioners can perform with self-confidence and finesse, if he or she adheres to the basic rules of surgical asepsis and technique.</p>
<p align="justify"> </p>
<p align="justify">Improvisation and adaptation, however, are sometimes required when dealing with very large, overweight patients, patients that have had a caesarean section or other abdominal procedures previously, dystocia cases with retained or decomposed foetuses, pyometra cases, and patients with gravid uterine horns in an inguinal or ventral abdominal hernia.</p>
<p align="justify"> </p>
<p align="justify">Certain breeds like the bullterrier, German shepherd and Staffordshire bullterrier tend to have very short and stubby ovarian suspensory ligaments, and the surgeon will require a firmer but more stable hand to stretch the ligament and exteriorise the ovarian pedicle. Different breeds also have differing premedication and anaesthetic tolerances. Highly strung and aggressive animals present a greater anaesthetic risk, and even the recovery period may differ in certain breeds and individual animals.</p>
<p align="justify"> </p>
<p align="justify">Although this article will concentrate mainly on the surgical complications of sterilisation, the holistic approach to admission of any surgical patient should be worked out and followed in a disciplined way.</p>
<p align="justify"> </p>
<p align="justify">ADMISSION PROCEDURE:</p>
<p align="justify"> </p>
<p align="justify">These aspects have been dealt with in previous newsletters, but just to summarise:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify"> </p>
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The owner should complete an admission form detailing the patient’s past medical history and present health status, and giving consent for the procedure to be performed.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A thorough clinical examination should be performed by the veterinarian or an experienced nurse (not lay staff) and all findings should be recorded.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Undetected subclinical conditions (e.g. long-standing diaphragmatic hernia, especially in a cat) may result in a life-threatening situation when the patient is anaesthetised. A carefully taken history and efficient pre-operative examination will increase the chances of detecting such subclinical conditions.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The anaesthetic protocol should be planned and recorded for every surgical procedure.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Post-operative observation should be performed by well-trained support staff, who can notice, evaluate and interpret the stages and signs of normal anaesthetic recovery, and identify danger signs such as bleeding, respiratory distress prolonged recovery time, hypothermia etc.</td>
</tr>
</tbody>
</table>
<p><span style="text-decoration: underline;"> </span></p>
<p align="justify"><span style="text-decoration: underline;">SURGICAL PROCEDURE</span><em>:</em></p>
<p><em></em></p>
<p align="justify">Once anaesthesia has been induced and an appropriately sized endotracheal tube has been placed and secured, the anaesthesia should, if at all possible, be maintained by halothane and oxygen inhalation. A cardiac and respiratory monitor will greatly complement your surgical procedures and should give an early warning of problems.</p>
<ol>
<p align="justify"> </p>
<li>Prepare (clip hair, wash and disinfect) the ventral abdomen from xiphoid to pubis, and from flank fold to flank fold (the area should rather be too big than too small – make provision for possibly having to extend the initial incision). After carefully expressing the bladder, transfer the patient from the prep room to the theatre.</li>
<p align="justify"> </p>
<li>Scrub, gown and glove. Open and pack out the instrument set. Drape the patient. Preferably, the patient and table should be completely covered - only the area around the intended site of incision should be visible. The size of the drape opening is determined by the anticipated procedure and the size of the patient.</li>
<p align="justify"> </p>
<li>Surgical incision – skin, subcutaneous tissue, linea alba and peritoneum. The incision length depends on patient size and the anticipated procedure (e.g. routine ovariohysterectomy, pregnant ovariohysterectomy, pyometra). The incision should rather be too liberal than too conservative. Unnecessary probing and cutting of the rectus sheath and the creation of cavities could result in post-operative inflammation, seroma or haematoma.</li>
<p align="justify"> </p>
<li>When entering the abdominal cavity, beware of a possibly enlarged spleen (splenomegaly with barbiturate induction!), an overfilled urinary bladder or insufficient depth of anaesthesia. The small intestine, omentum or mesentery can prolapse through the wound while the surgeon is making the incision. BLEEDING FROM THE SPLEEN AND MESENTERY, AND LEAKAGE FROM THE BLADDER AND INTESTINES CAN OCCUR WITHOUT THE SURGEON EVEN NOTICING.</li>
<p align="justify"> </p>
<li>Use the ovary hook to search for the uterine horns in the correct abdominal quadrant. No force should be used and the surgeon should be able to distinguish between the fat of the omentum, mesentery and broad ligament of the uterus. The surgeon should familiarise him/herself with the differences in appearance and texture of the round ligament of the uterus and the ureter. Ligation of the ureter will lead to HYDRONEPHROSIS and or PYELONEPHROSIS with likely devastating consequences.</li>
<p align="justify"> </p>
<li>Exteriorisation of the ovary by gentle and careful traction on the ovarian suspensory ligament is a procedure that can only be perfected by experience. Never become complacent with this step. In certain breeds like the bullterrier, German Shepherd and Staffordshire bullterrier, the suspensory ligament tends to be short and very difficult to stretch or break. Overzealous traction can cause haemorrhage where the ligament originates from the middle and ventral thirds of the last one or two ribs. The convoluted left and right ovarian arteries arise directly from the aorta - the tortuousity of these vessels is a built-in safety mechanism against rupturing when subjected to traction. Vascular branches to the adipose tissue and kidney capsule must be kept in mind when ligating the ovarian vessels. Accidental incorporation of omental, mesenteric and/or falciform fat can predispose to LIGATURE SLIPPAGE with immediate or delayed bleeding (blood pressure rises when animal wakes up). SPECIAL CARE SHOULD BE TAKEN WHEN LIGATING THESE STRUCTURES WHEN:</li>
</ol>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify"> </p>
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the patient is in oestrus – blood vessels are enlarged and there is a definite bleeding tendency; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">there is uterine infection; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">there are fallopian tube adhesions and infection; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the patient is overweight; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the patient has very short, stubby and strong ovarian suspensory ligaments; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the plane of anaesthesia is too light with insufficient abdominal muscle relaxation;</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the abdominal incision is too small or incorrectly placed.</td>
</tr>
</tbody>
</table>
<p align="justify">Every surgeon loves a small, neat wound because this is the only evidence of his/her surgical skill that the client sees – the so-called "surgeon’s signature". However, it should be borne in mind that A LONGER INCISION AND SURVIVING PATIENT ARE PREFERABLE TO A TINY WOUND AND EXSANGUINATED PATIENT.</p>
<p align="justify">It is obviously very important to remove each ovary completely and this should be verified by opening the ovarian bursa – this small step may well save you the embarrassment of having to deal with the OVARIAN REMNANT SYNDROME. Finding such an ovarian remnant a few months later is not impossible, but requires exposing the patient to additional unnecessary anaesthetic and surgical risk.</p>
<ol>
<p align="justify"> </p>
<li>Once the ovarian pedicle has been ligated and transected, carefully lift the uterine horn out of the abdominal cavity. Ligate the</li>
<p align="justify">mesometerium to prevent oozing from the smaller branches of the uterine artery and vein. In very young and lean patients, bleeding is generally not a problem, but in older and obese patients ligation is mandatory.</p>
<p align="justify">In ovariohysterectomy both ovaries, both uterine horns and the body of the uterus should be removed. The uterine arteries should always be ligated individually in large patients (over 20kg), when the uterus is diseased, and in pregnant and very fat patients. An additional ligature caudal to these individually ligated vessels should encircle the uterine vessels and uterine body (but not include any fat), 0.5 to 1cm from the cervical orifice. WHEN LIGATING THE UTERINE BODY, BLEEDING SHOULD BE AVOIDED AT ALL COSTS. Avoid excessive traction and ensure that the bladder, ureters, colon and fat are not included in any ligature. Time and effort spent here is well-invested because haemorrhage will claim valuable time and result in a blood-filled abdominal cavity. Dealing with bleeding that is totally obscuring your vision can be an extremely stressful experience. IN THE HASTE TO FIND THE POINT OF BLEEDING, IT IS EASY FOR GAUZE SWABS TO FIND THEIR WAY TO A "FORGOTTEN CORNER" OF THE ABDOMINAL CAVITY. Using large abdominal swabs (with tag and radiopaque marker) and suction is a more reliable way of restoring visibility and helps to avoid the STRAY SWAB INTRA-ABDOMINALLY.</p>
<p align="justify">There are many theories on how best to deal with the uterine stump after a caesarean-pan hysterectomy, pyometra or an in-oestrus ovariohysterectomy in a large patient. Thorough cleaning of the stump with sterile Ringers solution, over-sewing the loose ends of the stump and covering it with omentum can minimise granuloma formation by reaction around the stump. Using high quality suture material to tie ligatures will complement your technique and lessen complications - avoid cheap alternatives! Multifilament non-absorbable suture material should never be used because a FOREIGN BODY reaction is inevitable. The resultant SUBLUMBAR DRAINING TRACTS which may develop will force you to search for and completly remove all the ligatures tied with such material. PYOMETRA CAN DEVELOP in the remaining uterine body if too much of this organ is left behind.</p>
<p align="justify"> </p>
<li>Rough handling of the abdominal organs, excessive bleeding, and haematoma formation in the fat of the uterine broad ligament and mesentery, and around the urinary bladder will predispose to intra-abdominal inflammation and infection.</li>
<p align="justify">Performing a caesarean section, panhysterectomy with dead or decomposed foetuses, pyometra with perimetritis and leakage of uterine fluid into the abdominal cavity can cause life-threatening sepsis and extensive adhesions between the abdominal organs. POST-OPERATIVE SWELLING AROUND THE UTERINE STUMP SHOULD BE ANTICIPATED when dealing with the above mentioned conditions. HARD GRANULOMATOUS ADHESIONS BETWEEN UTERINE STUMP, URINARY BLADDER AND RECTUM may interfere with urination and defecation, and should be anticipated and handled to prevent pain and misery to the animal.</p>
<p align="justify"> </p>
<li>Suturing the abdominal incision.</li>
<p align="justify">Muscle layers: If the initial incision was made correctly through the linea alba, (the midventral strip of collagenous tissue extending from the xiphoid process to the pelvic symphysis), and not incorrectly through the rectus abdominis muscles, BLEEDING AND BLOOD OOZING FROM MUSCULAR VESSELS will be eliminated and sutures should not incorporate the peritoneum. Care should be taken to ensure that the cranial and caudal commissures of the surgical wound are closed properly with a suitable suture pattern using monofilament nylon. According to the literature the incidence of DEHISCENCE will increase if chromic catgut is used and all the muscle layers and peritoneum are included in the sutures. Obliterating subcutaneous dead space by placing 2–4 subcutaneous sutures will prevent SEROMA FORMATION AND WOUND SWELLING, and will ensure an acceptably neat surgical wound with no tension on the skin sutures. INCISIONAL HERNIAS occur acutely within 7 days post-operatively or occasionally weeks after surgery. This embarrassing complication may be caused by fat entrapment, inappropriate suture material, crushing sutures and poor knot tying technique. An inflamed wound, red and swollen with serosanguineus discharge 3–5 days post-operatively may be associated with EVISCERATION. This complication requires aggressive correction and support therapy. Bleeding from the subcutaneous tissue, seroma formation, swelling, skin sutures tied too tightly, and injury of skin around or near the wound, may lead to SELF MUTILATION OF THE WOUND, INFECTION AND FOREIGN BODY REACTION of the subcutaneous sutures with discharging sinus formation.</p>
<li>Animals sterilised when in oestrus should be kept away from male dogs for at least another 12–14 days. When discharging such a patient</li>
<p align="justify">from hospital, the owner should hear this message loud and clear. SEVERE DAMAGE CAN BE INFLICTED by the male dog while the patient is still emitting an oestrus odour.</p>
<p align="justify"> </p>
<li>To maintain good client relationships, each owner should be spoken to by the veterinarian or nurse, and their responsibilities explained as</li>
<p align="justify">far as wound examination and post-operative care of their pet is concerned. Advice on correct feeding and physical activity, especially in certain inactive breeds (to prevent obesity after sterilisation) is mandatory and will be appreciated by the owners.</p>
<p align="justify"> </p>
<li>When the patient is presented for suture removal, the veterinarian or his nurse will have another opportunity to inspect the wound, palpate</li>
</ol>
<p align="justify">the abdomen, stress the importance of correct feeding and deliberate physical activity, and the vague possibility of urinary incontinence.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify">Loosing a patient presented for sterilisation is an awful, nightmarish experience and can be extremely detrimental to your practice, your name and the profession. Everything possible within your power should be done to prevent catastrophes and complications, for the sake of our patients, clients, profession, practice and personal peace of mind and job satisfaction.</p>
<p align="justify">The last word is still not written about this aspect of our work. Many more complications can be added by surgeons performing these procedures. Let us keep on striving for perfection and only be satisfied with excellence.</p>
</table>
<p><strong>
<p align="justify">Recommended reading:</p>
</strong></p>
<p align="justify"> </p>
<p><em>
<p align="justify">Current Techniques in Small Animal Surgery</p>
</em></p>
<p align="justify">Bojrab MJ (ed). 3<sup>rd</sup> edition 1990, Lea &amp; Febiger, Philadelphia</p>
<p><em>
<p align="justify">Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat</p>
</em></p>
<p align="justify">Ettinger SJ, Feldman EC (eds). 5<sup>th</sup> edition 2000, W.B. Saunders, Philadelphia</p>
<p><em>
<p align="justify">Saunders Manual of Small Animal Practice</p>
</em></p>
<p align="justify">Birchard SJ , Sherding RG (eds). 2<sup>nd</sup> edition 2000, W.B. Saunders, Philadelphia</p>
<p><strong>
<p align="justify">Reviewed by:</p>
</strong></p>
<p align="justify">1. Dr W. Venning. Germiston Veterinary Hospital. Tel. No. (011) 902-2506</p>
<p align="justify">2. Dr T. Jacobs. Brackenhurst Veterinary Clinic. Tel. No. (011) 867-3631</p>
<p><em>(Published- September 2002, courtesy of Dr J L Möller)</em></p>
<p> </p></div><div class="feed-description"><p><strong>
<p align="center">GUIDELINES FOR PERFORMING &amp; POSSIBLE COMPLICATIONS OF OVARIOHYSTERECTOMY IN THE BITCH &amp; QUEEN</p>
</strong></p>
<p align="center">Compiled by Dr J.L. Möller BVSc(Hons), MMedVet(Chir)</p>
<p align="justify">Sterilisation of the bitch and queen by ovariohysterectomy should be one of the procedures that most veterinary practitioners can perform with self-confidence and finesse, if he or she adheres to the basic rules of surgical asepsis and technique.</p>
<p align="justify"> </p>
<p align="justify">Improvisation and adaptation, however, are sometimes required when dealing with very large, overweight patients, patients that have had a caesarean section or other abdominal procedures previously, dystocia cases with retained or decomposed foetuses, pyometra cases, and patients with gravid uterine horns in an inguinal or ventral abdominal hernia.</p>
<p align="justify"> </p>
<p align="justify">Certain breeds like the bullterrier, German shepherd and Staffordshire bullterrier tend to have very short and stubby ovarian suspensory ligaments, and the surgeon will require a firmer but more stable hand to stretch the ligament and exteriorise the ovarian pedicle. Different breeds also have differing premedication and anaesthetic tolerances. Highly strung and aggressive animals present a greater anaesthetic risk, and even the recovery period may differ in certain breeds and individual animals.</p>
<p align="justify"> </p>
<p align="justify">Although this article will concentrate mainly on the surgical complications of sterilisation, the holistic approach to admission of any surgical patient should be worked out and followed in a disciplined way.</p>
<p align="justify"> </p>
<p align="justify">ADMISSION PROCEDURE:</p>
<p align="justify"> </p>
<p align="justify">These aspects have been dealt with in previous newsletters, but just to summarise:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify"> </p>
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The owner should complete an admission form detailing the patient’s past medical history and present health status, and giving consent for the procedure to be performed.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">A thorough clinical examination should be performed by the veterinarian or an experienced nurse (not lay staff) and all findings should be recorded.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Undetected subclinical conditions (e.g. long-standing diaphragmatic hernia, especially in a cat) may result in a life-threatening situation when the patient is anaesthetised. A carefully taken history and efficient pre-operative examination will increase the chances of detecting such subclinical conditions.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">The anaesthetic protocol should be planned and recorded for every surgical procedure.</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Post-operative observation should be performed by well-trained support staff, who can notice, evaluate and interpret the stages and signs of normal anaesthetic recovery, and identify danger signs such as bleeding, respiratory distress prolonged recovery time, hypothermia etc.</td>
</tr>
</tbody>
</table>
<p><span style="text-decoration: underline;"> </span></p>
<p align="justify"><span style="text-decoration: underline;">SURGICAL PROCEDURE</span><em>:</em></p>
<p><em></em></p>
<p align="justify">Once anaesthesia has been induced and an appropriately sized endotracheal tube has been placed and secured, the anaesthesia should, if at all possible, be maintained by halothane and oxygen inhalation. A cardiac and respiratory monitor will greatly complement your surgical procedures and should give an early warning of problems.</p>
<ol>
<p align="justify"> </p>
<li>Prepare (clip hair, wash and disinfect) the ventral abdomen from xiphoid to pubis, and from flank fold to flank fold (the area should rather be too big than too small – make provision for possibly having to extend the initial incision). After carefully expressing the bladder, transfer the patient from the prep room to the theatre.</li>
<p align="justify"> </p>
<li>Scrub, gown and glove. Open and pack out the instrument set. Drape the patient. Preferably, the patient and table should be completely covered - only the area around the intended site of incision should be visible. The size of the drape opening is determined by the anticipated procedure and the size of the patient.</li>
<p align="justify"> </p>
<li>Surgical incision – skin, subcutaneous tissue, linea alba and peritoneum. The incision length depends on patient size and the anticipated procedure (e.g. routine ovariohysterectomy, pregnant ovariohysterectomy, pyometra). The incision should rather be too liberal than too conservative. Unnecessary probing and cutting of the rectus sheath and the creation of cavities could result in post-operative inflammation, seroma or haematoma.</li>
<p align="justify"> </p>
<li>When entering the abdominal cavity, beware of a possibly enlarged spleen (splenomegaly with barbiturate induction!), an overfilled urinary bladder or insufficient depth of anaesthesia. The small intestine, omentum or mesentery can prolapse through the wound while the surgeon is making the incision. BLEEDING FROM THE SPLEEN AND MESENTERY, AND LEAKAGE FROM THE BLADDER AND INTESTINES CAN OCCUR WITHOUT THE SURGEON EVEN NOTICING.</li>
<p align="justify"> </p>
<li>Use the ovary hook to search for the uterine horns in the correct abdominal quadrant. No force should be used and the surgeon should be able to distinguish between the fat of the omentum, mesentery and broad ligament of the uterus. The surgeon should familiarise him/herself with the differences in appearance and texture of the round ligament of the uterus and the ureter. Ligation of the ureter will lead to HYDRONEPHROSIS and or PYELONEPHROSIS with likely devastating consequences.</li>
<p align="justify"> </p>
<li>Exteriorisation of the ovary by gentle and careful traction on the ovarian suspensory ligament is a procedure that can only be perfected by experience. Never become complacent with this step. In certain breeds like the bullterrier, German Shepherd and Staffordshire bullterrier, the suspensory ligament tends to be short and very difficult to stretch or break. Overzealous traction can cause haemorrhage where the ligament originates from the middle and ventral thirds of the last one or two ribs. The convoluted left and right ovarian arteries arise directly from the aorta - the tortuousity of these vessels is a built-in safety mechanism against rupturing when subjected to traction. Vascular branches to the adipose tissue and kidney capsule must be kept in mind when ligating the ovarian vessels. Accidental incorporation of omental, mesenteric and/or falciform fat can predispose to LIGATURE SLIPPAGE with immediate or delayed bleeding (blood pressure rises when animal wakes up). SPECIAL CARE SHOULD BE TAKEN WHEN LIGATING THESE STRUCTURES WHEN:</li>
</ol>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify"> </p>
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the patient is in oestrus – blood vessels are enlarged and there is a definite bleeding tendency; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">there is uterine infection; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">there are fallopian tube adhesions and infection; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the patient is overweight; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the patient has very short, stubby and strong ovarian suspensory ligaments; and</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the plane of anaesthesia is too light with insufficient abdominal muscle relaxation;</td>
</tr>
<p align="justify"> </p>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">the abdominal incision is too small or incorrectly placed.</td>
</tr>
</tbody>
</table>
<p align="justify">Every surgeon loves a small, neat wound because this is the only evidence of his/her surgical skill that the client sees – the so-called "surgeon’s signature". However, it should be borne in mind that A LONGER INCISION AND SURVIVING PATIENT ARE PREFERABLE TO A TINY WOUND AND EXSANGUINATED PATIENT.</p>
<p align="justify">It is obviously very important to remove each ovary completely and this should be verified by opening the ovarian bursa – this small step may well save you the embarrassment of having to deal with the OVARIAN REMNANT SYNDROME. Finding such an ovarian remnant a few months later is not impossible, but requires exposing the patient to additional unnecessary anaesthetic and surgical risk.</p>
<ol>
<p align="justify"> </p>
<li>Once the ovarian pedicle has been ligated and transected, carefully lift the uterine horn out of the abdominal cavity. Ligate the</li>
<p align="justify">mesometerium to prevent oozing from the smaller branches of the uterine artery and vein. In very young and lean patients, bleeding is generally not a problem, but in older and obese patients ligation is mandatory.</p>
<p align="justify">In ovariohysterectomy both ovaries, both uterine horns and the body of the uterus should be removed. The uterine arteries should always be ligated individually in large patients (over 20kg), when the uterus is diseased, and in pregnant and very fat patients. An additional ligature caudal to these individually ligated vessels should encircle the uterine vessels and uterine body (but not include any fat), 0.5 to 1cm from the cervical orifice. WHEN LIGATING THE UTERINE BODY, BLEEDING SHOULD BE AVOIDED AT ALL COSTS. Avoid excessive traction and ensure that the bladder, ureters, colon and fat are not included in any ligature. Time and effort spent here is well-invested because haemorrhage will claim valuable time and result in a blood-filled abdominal cavity. Dealing with bleeding that is totally obscuring your vision can be an extremely stressful experience. IN THE HASTE TO FIND THE POINT OF BLEEDING, IT IS EASY FOR GAUZE SWABS TO FIND THEIR WAY TO A "FORGOTTEN CORNER" OF THE ABDOMINAL CAVITY. Using large abdominal swabs (with tag and radiopaque marker) and suction is a more reliable way of restoring visibility and helps to avoid the STRAY SWAB INTRA-ABDOMINALLY.</p>
<p align="justify">There are many theories on how best to deal with the uterine stump after a caesarean-pan hysterectomy, pyometra or an in-oestrus ovariohysterectomy in a large patient. Thorough cleaning of the stump with sterile Ringers solution, over-sewing the loose ends of the stump and covering it with omentum can minimise granuloma formation by reaction around the stump. Using high quality suture material to tie ligatures will complement your technique and lessen complications - avoid cheap alternatives! Multifilament non-absorbable suture material should never be used because a FOREIGN BODY reaction is inevitable. The resultant SUBLUMBAR DRAINING TRACTS which may develop will force you to search for and completly remove all the ligatures tied with such material. PYOMETRA CAN DEVELOP in the remaining uterine body if too much of this organ is left behind.</p>
<p align="justify"> </p>
<li>Rough handling of the abdominal organs, excessive bleeding, and haematoma formation in the fat of the uterine broad ligament and mesentery, and around the urinary bladder will predispose to intra-abdominal inflammation and infection.</li>
<p align="justify">Performing a caesarean section, panhysterectomy with dead or decomposed foetuses, pyometra with perimetritis and leakage of uterine fluid into the abdominal cavity can cause life-threatening sepsis and extensive adhesions between the abdominal organs. POST-OPERATIVE SWELLING AROUND THE UTERINE STUMP SHOULD BE ANTICIPATED when dealing with the above mentioned conditions. HARD GRANULOMATOUS ADHESIONS BETWEEN UTERINE STUMP, URINARY BLADDER AND RECTUM may interfere with urination and defecation, and should be anticipated and handled to prevent pain and misery to the animal.</p>
<p align="justify"> </p>
<li>Suturing the abdominal incision.</li>
<p align="justify">Muscle layers: If the initial incision was made correctly through the linea alba, (the midventral strip of collagenous tissue extending from the xiphoid process to the pelvic symphysis), and not incorrectly through the rectus abdominis muscles, BLEEDING AND BLOOD OOZING FROM MUSCULAR VESSELS will be eliminated and sutures should not incorporate the peritoneum. Care should be taken to ensure that the cranial and caudal commissures of the surgical wound are closed properly with a suitable suture pattern using monofilament nylon. According to the literature the incidence of DEHISCENCE will increase if chromic catgut is used and all the muscle layers and peritoneum are included in the sutures. Obliterating subcutaneous dead space by placing 2–4 subcutaneous sutures will prevent SEROMA FORMATION AND WOUND SWELLING, and will ensure an acceptably neat surgical wound with no tension on the skin sutures. INCISIONAL HERNIAS occur acutely within 7 days post-operatively or occasionally weeks after surgery. This embarrassing complication may be caused by fat entrapment, inappropriate suture material, crushing sutures and poor knot tying technique. An inflamed wound, red and swollen with serosanguineus discharge 3–5 days post-operatively may be associated with EVISCERATION. This complication requires aggressive correction and support therapy. Bleeding from the subcutaneous tissue, seroma formation, swelling, skin sutures tied too tightly, and injury of skin around or near the wound, may lead to SELF MUTILATION OF THE WOUND, INFECTION AND FOREIGN BODY REACTION of the subcutaneous sutures with discharging sinus formation.</p>
<li>Animals sterilised when in oestrus should be kept away from male dogs for at least another 12–14 days. When discharging such a patient</li>
<p align="justify">from hospital, the owner should hear this message loud and clear. SEVERE DAMAGE CAN BE INFLICTED by the male dog while the patient is still emitting an oestrus odour.</p>
<p align="justify"> </p>
<li>To maintain good client relationships, each owner should be spoken to by the veterinarian or nurse, and their responsibilities explained as</li>
<p align="justify">far as wound examination and post-operative care of their pet is concerned. Advice on correct feeding and physical activity, especially in certain inactive breeds (to prevent obesity after sterilisation) is mandatory and will be appreciated by the owners.</p>
<p align="justify"> </p>
<li>When the patient is presented for suture removal, the veterinarian or his nurse will have another opportunity to inspect the wound, palpate</li>
</ol>
<p align="justify">the abdomen, stress the importance of correct feeding and deliberate physical activity, and the vague possibility of urinary incontinence.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify">Loosing a patient presented for sterilisation is an awful, nightmarish experience and can be extremely detrimental to your practice, your name and the profession. Everything possible within your power should be done to prevent catastrophes and complications, for the sake of our patients, clients, profession, practice and personal peace of mind and job satisfaction.</p>
<p align="justify">The last word is still not written about this aspect of our work. Many more complications can be added by surgeons performing these procedures. Let us keep on striving for perfection and only be satisfied with excellence.</p>
</table>
<p><strong>
<p align="justify">Recommended reading:</p>
</strong></p>
<p align="justify"> </p>
<p><em>
<p align="justify">Current Techniques in Small Animal Surgery</p>
</em></p>
<p align="justify">Bojrab MJ (ed). 3<sup>rd</sup> edition 1990, Lea &amp; Febiger, Philadelphia</p>
<p><em>
<p align="justify">Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat</p>
</em></p>
<p align="justify">Ettinger SJ, Feldman EC (eds). 5<sup>th</sup> edition 2000, W.B. Saunders, Philadelphia</p>
<p><em>
<p align="justify">Saunders Manual of Small Animal Practice</p>
</em></p>
<p align="justify">Birchard SJ , Sherding RG (eds). 2<sup>nd</sup> edition 2000, W.B. Saunders, Philadelphia</p>
<p><strong>
<p align="justify">Reviewed by:</p>
</strong></p>
<p align="justify">1. Dr W. Venning. Germiston Veterinary Hospital. Tel. No. (011) 902-2506</p>
<p align="justify">2. Dr T. Jacobs. Brackenhurst Veterinary Clinic. Tel. No. (011) 867-3631</p>
<p><em>(Published- September 2002, courtesy of Dr J L Möller)</em></p>
<p> </p></div>Guidelines - Parvo Viral Diarrhoea2009-09-02T10:32:14+00:002009-09-02T10:32:14+00:00http://www.savc.org.za/act-rule-regulations-forms/regulations/15-savc/guidelines/234-guidelines-parvo-viral-diarrhoeaAdministratorwebmaster@savc.org.za<div class="feed-description"><p align="center">PARVO VIRAL DIARRHOEA</p>
<p>These guidelines for Parvo virosis (or any very ill puppy with severe acute diarrhoea) were compiled by members of and are currently in use at Onderstepoort<strong><em> </em></strong>in the Section of Small Animal Medicine, Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria.</p>
<p>Compiled by: Dr. Dave Miller <a href="mailto:dmiller@op.up.ac.za">dmiller@op.up.ac.za</a> P/Bag X 04, Onderstepoort, 0110, SA</p>
<p><strong><span style="text-decoration: underline;">
<p>Introduction:</p>
</span></strong></p>
<p>Acute diarrhoea is second only to pruritus in prevalence in dogs presented to veterinarians. There is, however, a large difference in the pathophysiology and the consequences between a " run of the mill acute diarrhoea" and a puppy suffering from parvo viral diarrhoea.</p>
<p>Until recently we have treated all acute diarrhoea cases alike! No food until the vomiting and diarrhoea have stopped and then small amounts of low fat foods if the dog would eat voluntarily. This implies that many of these young puppies would go 3-10 days without food!</p>
<p>Over the years advances have occurred in the fields of pain control, fluid administration, antibiotic therapy and basic care of these patients. There has also been a paradigm shift in our thinking towards feeding! We have recognised that puppies with <em>parvo</em> are not just acute diarrhoea cases and not only must we feed them as soon as possible, but if they do not eat on their own, we should tube feed them!</p>
<p>Table1: Normal physiology of the small intestines.</p>
<table border="1" cellspacing="1" cellpadding="7" width="568">
<tbody>
<tr>
<td valign="top"><strong>
<p>The Mucosal lining of the GIT.</p>
</strong>
<p>The intestinal epithelial cells carry out a multitude of functions:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Villus crypts: function primarily to secrete fluid into the bowel.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">After division, the cells migrate up the villus from the crypt reaching the tip in 3-5 days. During migration, the cells mature and change their primary function from secretion to surface digestion and absorption.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Villus tip: carries out final stages of protein and carbohydrate digestion together with absorption of nutrients, salts and water.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Normal mucosal integrity and function are usually restored in 2-3 days, provided the inciting cause is eliminated and the initial insult was not sufficiently severe to damage the crypts.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Rapid cell turnover is the major reason why most <strong>acute</strong> diseases of the small intestine are self-limiting.</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">
<p>Acute Small Intestinal Diarrhoea.</p>
</span></strong></p>
<p>This is an otherwise healthy dog that has diarrhoea. The dog has an acute onset of diarrhoea with or without vomiting and the dog may or may not be depressed (e.g. overeating, garbage disease [preformed toxin], diet change etc.).</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Abrupt onset diarrhoea that has a short clinical course that ranges from transient and self-limiting to fulminating and explosive.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Typical treatment of acute diarrhoea:</td>
</tr>
</tbody>
</table>
<p>Needs only <strong>supportive and symptomatic therapy,</strong> since most animals that die from diarrhoea do so not as a result of the inciting cause but from the loss of electrolytes and water, with subsequent <span style="text-decoration: underline;">dehydration</span>, acidosis and shock.</p>
<p><strong><span style="text-decoration: underline;">
<p>Non-specific, symptomatic treatment of acute diarrhoea:</p>
</span></strong></p>
<p>In cases, where foreign bodies and systemic diseases causing the diarrhoea have been ruled out, treatment may not always be indicated as many animals improve spontaneously in a day or two without treatment.</p>
<p>General treatment measures (if needed) include:</p>
<p>- Dietary restriction 6- 12 hours (preferably not longer in young puppies or toy breeds).</p>
<p>(Dogs over 4-6 months can go 12-20 hours without food.)</p>
<p>- Maintenance of fluid and electrolyte levels and acid-base homeostasis.</p>
<p>- Rarely anti-bacterials</p>
<p>- Anti-emetics</p>
<p><strong>
<p>Anti-emetics</p>
</strong></p>
<p>PLEASE DON’T LET THEM VOMIT!!!!!!!!!!!!!!</p>
<p>Once FB ruled out – dispense metoclopramide (0.2-0.5 mg/kg po or sc Tid/Qid)</p>
<p><strong>
<p>Dietary Restriction:</p>
</strong></p>
<p>- Rest the GI tract. Withhold food 6-12 hours (or more).</p>
<p>Biological system -Toy breed puppy 4-6 hours, adult Staffie 6 - 18h.</p>
<p>- Feed small, bland meals frequently when resume feeding (as soon as possible)</p>
<p>[We use commercial intestinal diets]</p>
<p>- Gradually convert to regular commercial puppy/adult food over 2-3 days once the</p>
<p>diarrhoea resolves.</p>
<p>Antibacterials: (For acute diarrhoea in non-collapsed dog)</p>
<p>Antibiotics have long been part of standard treatment of acute and chronic diarrhoea; yet there is no evidence for bacterial infection as a major cause of diarrhoea in small animals. Therefore, there is little or no indication for the routine use of oral antimicrobials in the treatment of diarrhoea in small animals.</p>
<p>Antibiotics are <strong>only</strong> <strong>indicated</strong> when extensive damage to the intestinal mucosal barrier occurs. Mucosal damage is thought to allow penetration of the intestinal wall by bacteria with subsequent entry into the systemic circulation. The following findings indicate the need for antibacterial therapy.</p>
<p>- Fever</p>
<p>- Collapse</p>
<p>- Left shift neurophilia with or without degenerative or toxic neutrophil changes.</p>
<p>- Haemorrhagic diarrhoea</p>
<table border="1" cellspacing="1" cellpadding="7" width="538">
<tbody>
<tr>
<td valign="top">
<p align="left">Normal intestinal flora are protective of the host, inhibiting colonisation by pathogenic organisms. The disruption of bacterial flora exposes the host to more pathogenic processes and may prolong the return of normal intestinal function and homeostasis.</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p>Fluid therapy:</p>
</strong></p>
<p>Mild dehydration often causes anorexia.</p>
<p>Unless the patient needs i.v. fluids, we often give 5% rehydration fluids sub-cutaneously or intra-peritonealy and the patient is sent home.</p>
<p>[BW x 5% x 10 = fluid (ml) administered]</p>
<p><strong><span style="text-decoration: underline;">
<p>WHAT ABOUT PARVO?</p>
</span></strong></p>
<p>Parvo virus colonises fast-dividing cell lines and through it’s replication process, destroys them. The typical parvo puppy thus loses:</p>
<p>- its bone marrow, lymphoid tissue and the enterocytes lining the GIT.</p>
<p>So one is left with an immunocompromised dog which is likely to develop septicaemia from enteric bacteria.</p>
<p>2002: Treatment Protocol for Canine Parvo Virus:</p>
<p>This is the <em>"Ideal General Approach"</em> to cases - Remember<span style="text-decoration: underline;"> this is</span> a "<em><span style="text-decoration: underline;">biological system</span></em>" so be flexible!!!!!!!!</p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>At admission</strong></p>
</td>
<td valign="middle">
<p align="justify">Place IV catheter / IV amoxycillin / Ht / TSP/glucose/K</p>
<p align="justify">Replacement fluid with 20 meq. KCL(1 vial) + 20 ml 50% dextrose in 1l ringer lactate.</p>
<p align="justify">[<em>This gives a 1% dextrose solution</em> - <em>"Maintelyte with glucose 5%" glucose to high for rehydration and causes glycosuria]</em></p>
<p align="justify">Pain killers for abdominal pain – synthetic opioids (Temgesic).</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>1<sup>st</sup> 2 hours</strong></p>
</td>
<td valign="middle">
<p align="justify">Work out the sum of re-hydration + Maintenance (off table) for 1<sup>st</sup> 12 hours</p>
<p align="justify">Give ¼ to ½ of amount over first 2 hours to correct intra-vascular volume and blood pressure (warm fluids to body temp).</p>
<p align="justify">If in shock – apply first principles for shock therapy.</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>After 1<sup>st</sup> 2 hrs</strong></p>
</td>
<td valign="middle">
<p align="justify">Give rest of fluid over next 10 hours. Test Ht + TSP + K + Glucose</p>
<p align="justify">Warm patient on heating pad at this point [<strong>NB – not before</strong> as progresses shock!]</p>
<p align="justify">(Spike drip with more glucose if needed. [50ml 50% =2.5% or 100ml 50% = 5%]</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>2-3 hrs</strong></p>
</td>
<td valign="middle">
<p align="justify">Metoclopramide either as an I.V. bolus or a constant rate infusion (CRI) - to treat ileus and/or vomiting (doses later in the document).</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx. 4 - 5 hrs.</strong></p>
</td>
<td valign="middle">
<p align="justify">Start to feed (aim for at least 1/3 of requirements over next 24 hours)</p>
<p align="justify">Work out requirements with formula – [(bwx30) +70] x illness factor (1.25 – 1.5)</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx. 12 hrs.</strong></p>
</td>
<td valign="middle">
<p align="justify">Re-assess hydration: continue rehydrating or change to</p>
<p align="justify">1 to 1 ½ x maintenance rate</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx. 12 hrs</strong></p>
</td>
<td valign="middle">
<p align="justify">Gentamicin IV if patient is rehydrated to cover gram-negative bacteria.</p>
<em> </em>
<p align="justify"><em>(check for urine in bladder, CRT&lt;2 sec’s) </em></p>
</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">
<p align="justify">Monitoring the Parvo puppy.</p>
</span></strong></p>
<p align="justify">The following <span style="text-decoration: underline;">should</span> ideally be monitored at admission, after 2 hours of fluids and then on a daily basis <strong>in patients that are still ill</strong>:</p>
<p align="center">USE PAEDIATRIC SAMPLING TUBES OR TAKE VERY SMALL QUANTITIES OF BLOOD.</p>
<p align="left">Fluid Therapy</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Rehydration</td>
</tr>
</tbody>
</table>
<p align="justify">- Body mass x 10 x % dehydration = volume in ml (give over 12 hours)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Maintenance</td>
</tr>
</tbody>
</table>
<p align="justify">- Refer to fluid tables!!!! (appended at the end)</p>
<p align="justify">(The formula 40 – 60 ml/kg/24 hours is <strong>not valid</strong> in patients under 10 kg)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ongoing losses</td>
</tr>
</tbody>
</table>
<p align="justify">Estimated at 10 – 20 ml/kg/24 Hrs (if still vomiting and diarrhoea)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Fluid Selection</td>
</tr>
</tbody>
</table>
<p align="justify">Calculate the re-hydration + maintenance + ongoing losses for first 12 hours and then rehydrate with:</p>
<table border="1" cellspacing="1" cellpadding="7" width="362">
<tbody>
<tr>
<td valign="top">
<p align="justify"> </p>
</td>
</tr>
</tbody>
</table>
<p align="center"><strong>è ¼ - ½ over first 2 hours then rest over 10 hours (check K infusion rates)</strong></p>
<p align="justify">Only once rehydration is achieved can maintenance fluids be used:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Decision dependant on patient condition.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">You should ideally place a central catheter.</td>
</tr>
</tbody>
</table>
<p align="justify">Short notes on spiking drips.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Always label drip bag!</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Never give potassium (K) as a bolus!</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Supplement K as shown in the table below <strong>only after rehydration is complete! </strong>Potassium given too fast is cardiotoxic</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify">– do not exceed 0.5meq of K /kg/h</p>
</table>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td colspan="3" valign="top">
<p align="center">POTASSIUM SUPPLEMENTATION (1 vial KCL 15 % = 20mEq)</p>
</td>
</tr>
<tr>
<td valign="top">
<p>Serum Potassium mEq/l of patient</p>
</td>
<td valign="top">
<p>Supplementation potassium (per 1000ml ) replacement fluid</p>
<p><strong>(mmol KCL = meq K<sup>+</sup>)</strong></p>
</td>
<td valign="top">
<p>MAXIMAL FLUID INFUSION RATE</p>
<p>(ml/kg/h)</p>
</td>
</tr>
<tr>
<td valign="top">
<p>3.5 – 5.5 (Normal)</p>
</td>
<td valign="top">
<p>20 mEq K (1 vial of 15%)</p>
</td>
<td valign="top">
<p>25</p>
</td>
</tr>
<tr>
<td valign="top">
<p>3.0 – 3.4</p>
</td>
<td valign="top">
<p>30 mEq K</p>
</td>
<td valign="top">
<p>18</p>
</td>
</tr>
<tr>
<td valign="top">
<p>2.5 – 2.9</p>
</td>
<td valign="top">
<p>40 mEq K</p>
</td>
<td valign="top">
<p>12</p>
</td>
</tr>
<tr>
<td valign="top">
<p>2.0 – 2.4</p>
</td>
<td valign="top">
<p>60 mEq K</p>
</td>
<td valign="top">
<p>8</p>
</td>
</tr>
<tr>
<td valign="top">
<p>&lt;2.0</p>
</td>
<td valign="top">
<p>80 mEq K</p>
</td>
<td valign="top">
<p>6</p>
</td>
</tr>
</tbody>
</table>
<p align="justify"><strong><span style="text-decoration: underline;">Antibiotic Therapy.</span></strong></p>
<p align="justify">Need to cover gram negative and positive as well as aerobic and anaerobic bacteria. The following antibiotics can be used:Amoxycillin - Amoxil 15 – 20 mg/kg IV TIDthen- penicillin’s p.o. s.c. i.v. 20 mg/kg BID(Change over when perfusion is deemed to be GOOD)Gentamicin - 3 mg/kg TID or 5 mg/kg BID, once patient is rehydrated</p>
<p align="justify"><strong>Bladder filling with urine shows rehydration and renal</strong> perfusion.</p>
<p align="justify">- Use until patient is clinically improved- 3-5 days max. (Not all patients will need Genta)Enrofloxacin - 2.5mg/kg BID IM/SC</p>
<p align="justify">used when gentamicin is contraindicated)</p>
<p align="justify"><strong>OWNER CONSENT IS NECESSARY!</strong></p>
<p align="justify">Avoid in large breeds - cartilage damage.</p>
<p align="justify"><strong>Nutrition.</strong></p>
<p align="justify"><strong><em>The previous "NIL PER OS"</em> <em>is not followed anymore!!</em></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Start to feed once rehydration is underway (+/- 4-12 hours after admission)</td>
</tr>
</tbody>
</table>
<p align="justify">(We try to never starve a puppy for longer than 6 hours once in hospital)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If possible aim for a minimum of 1/3 of nutritional requirements over next 24 hours</td>
</tr>
</tbody>
</table>
<p align="justify">([Body weight x 30] + 70) x illness factor. 1.25 -1.5 depending on clinical findings.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If still vomiting a lot, miss out 1-2 hours, cut back slightly on quantity but do not starve!</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Naso-oesophageal tube: can be placed at admission or 4-6 hours later.</td>
</tr>
</tbody>
</table>
<p align="justify">Information on Kcal/ml of some of the commonly fed foods formulated for this purpose in the isolation unit can be obtained from <span style="text-decoration: underline;">Council’s office.</span></p>
<p align="justify">We send them home with the 800gram Intestinal formula puppy food bags and instructions to feed only that for at least 3-7 days.</p>
<p align="justify"><strong><span style="text-decoration: underline;">Additional Therapy if Required:</span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<strong></strong>
<tbody>
<tr>
<td width="42" valign="baseline"><strong></strong></td>
<td width="100%" valign="top"><strong><span style="text-decoration: underline;"> Anti-emetics </span></strong></td>
</tr>
</tbody>
</table>
<p><strong></strong></p>
<p align="justify">Metoclopramide - first iv or sc and see the effect, if still vomiting, we use a CRI- 0.2 -0.4 mg/kg q6-8 hrly (iv/sc/im)- 1-2 mg/kg/day as a Constant rate infusion(CRI)<span style="text-decoration: underline;"><strong><em>Prochlorpronazine</em></strong> </span>- 0.5 mg/kg im/sc q 8 hrly</p>
<p align="justify">(No prokinetic effect)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Plasma transfusion - 20 ml/kg if albumin <strong>&lt; 20 g/dl</strong></td>
</tr>
</tbody>
</table>
<p align="justify">or - TSP &lt; 40.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Blood transfusion to be administered if the patient is not improving and/or the Ht &lt;15–20.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Hetastarch – 5-20 ml/kg bolus when patient is not improving but pain is controlled and the Ht, potassium, glucose and albumin levels are normal.</td>
</tr>
</tbody>
</table>
<p align="justify">In cases "not doing well" we use a constant rate infusion (CRI) of ½-2 ml/kg/h.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Deworm – 1ml/kg panacur OID P.O. 5 d. (If vomiting – Ivomec - need owner consent)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Temgesic 0.01mg/kg iv 6 hrly if <strong>ANY</strong> abdominal pain (need only a few treatments)</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Sucrulfate 1ml/3kg q6-8 hrly if dogs vomiting a lot (for reflux oesophagitis)</td>
</tr>
</tbody>
</table>
<p align="justify">Cimetidine 10 mg/kg I.V. TID or Ranitidine 2 mg/kg BID I.V.</p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td valign="top">
<p align="justify"><strong>NB: ALL NSAIDs ESPECIALLY THE OLDER PRODUCTS LIKE PHENYLBUTAZONE, AND FLUNIXIN MEG. ARE NEPHROTOXIC AND CAUSE GASTRIC ULCERS AND MUST BE AVOIDED IN ALL DOGS AND CATS WITH LOW BLOOD PRESSURE.</strong></p>
<p align="center">[e.g. general anaesthesia, diarrhoea, vomiting, heat stroke, hit by car, Babesiosis, shock etc.]</p>
</td>
</tr>
</tbody>
</table>
<p align="center"><strong>DAILY WATER REQUIREMENTS FOR DOGS AND CATS</strong></p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td colspan="4" valign="top"><strong> </strong>
<p align="center"><strong>Daily Water</strong></p>
<strong> </strong>
<p align="center"><strong>Requirements for the Dog*</strong></p>
</td>
<td valign="top"></td>
<td colspan="4" valign="top"><strong> </strong>
<p align="center"><strong>Daily Water</strong></p>
<strong> </strong>
<p align="center"><strong>Requirements for the Cat**</strong></p>
</td>
</tr>
<tr>
<td valign="top"><strong> </strong>
<p align="justify"><strong><br /></strong></p>
<strong> </strong>
<p align="justify"><strong>Body weight</strong></p>
<strong> </strong>
<p align="center"><strong>(kg)</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong>TOTAL</strong></p>
<strong> </strong>
<p align="center"><strong>WATER</strong></p>
<strong> </strong>
<p align="center"><strong>ml/day</strong></p>
</td>
<td valign="top"><strong> </strong>
<p><strong>/kg</strong></p>
</td>
<td valign="top"><strong> </strong>
<p><strong>/h</strong></p>
</td>
<td valign="top"></td>
<td valign="top"><strong> </strong>
<p align="center"><strong><br /></strong></p>
<strong> </strong>
<p align="center"><strong>Bodyweight</strong></p>
<strong> </strong>
<p align="center"><strong>(kg)</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong>TOTAL</strong></p>
<strong> </strong>
<p align="center"><strong>WATER</strong></p>
<strong> </strong>
<p align="center"><strong>ml/day</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong><br /></strong></p>
<strong> </strong>
<p align="center"><strong>/kg</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong>/h</strong></p>
</td>
</tr>
<tr>
<td rowspan="2" valign="top">
<p align="center">1</p>
<p align="center">2</p>
<p align="center">3</p>
<p align="center">4</p>
<p align="center">5</p>
<p align="center">6</p>
<p align="center">7</p>
<p align="center">8</p>
<p align="center">9</p>
<p align="center">10</p>
<p align="center">11</p>
<p align="center">12</p>
<p align="center">13</p>
<p align="center">14</p>
<p align="center">15</p>
<p align="center">16</p>
<p align="center">17</p>
<p align="center">18</p>
<p align="center">19</p>
<p align="center">20</p>
<p align="center">21</p>
<p align="center">22</p>
<p align="center">23</p>
<p align="center">24</p>
<p align="center">25</p>
<p align="center">26</p>
<p align="center">27</p>
<p align="center">28</p>
<p align="center">29</p>
<p align="center">30</p>
<p align="center">35</p>
<p align="center">40</p>
<p align="center">45</p>
<p align="center">50</p>
<p align="center">55</p>
<p align="center">60</p>
<p align="center">70</p>
<p align="center">80</p>
<p align="center">90</p>
<p align="center">100</p>
<p align="center"> </p>
</td>
<td rowspan="2" valign="top">
<p align="center">132</p>
<p align="center">214</p>
<p align="center">285</p>
<p align="center">348</p>
<p align="center">407</p>
<p align="center">463</p>
<p align="center">515</p>
<p align="center">566</p>
<p align="center">615</p>
<p align="center">662</p>
<p align="center">707</p>
<p align="center">752</p>
<p align="center">795</p>
<p align="center">837</p>
<p align="center">879</p>
<p align="center">919</p>
<p align="center">959</p>
<p align="center">998</p>
<p align="center">1037</p>
<p align="center">1075</p>
<p align="center">1112</p>
<p align="center">1149</p>
<p align="center">1185</p>
<p align="center">1221</p>
<p align="center">1256</p>
<p align="center">1291</p>
<p align="center">1326</p>
<p align="center">1360</p>
<p align="center">1394</p>
<p align="center">1427</p>
<p align="center">1590</p>
<p align="center">1746</p>
<p align="center">1896</p>
<p align="center">2041</p>
<p align="center">2182</p>
<p align="center">2319</p>
<p align="center">2583</p>
<p align="center">2836</p>
<p align="center">3080</p>
<p align="center">3316</p>
</td>
<td rowspan="2" valign="top">
<p align="center">132</p>
<p align="center">107</p>
<p align="center">95</p>
<p align="center">87</p>
<p align="center">81</p>
<p align="center">77</p>
<p align="center">74</p>
<p align="center">71</p>
<p align="center">68</p>
<p align="center">66</p>
<p align="center">64</p>
<p align="center">63</p>
<p align="center">61</p>
<p align="center">60</p>
<p align="center">59</p>
<p align="center">57</p>
<p align="center">56</p>
<p align="center">55</p>
<p align="center">55</p>
<p align="center">54</p>
<p align="center">53</p>
<p align="center">52</p>
<p align="center">52</p>
<p align="center">51</p>
<p align="center">50</p>
<p align="center">50</p>
<p align="center">49</p>
<p align="center">49</p>
<p align="center">48</p>
<p align="center">48</p>
<p align="center">45</p>
<p align="center">44</p>
<p align="center">42</p>
<p align="center">41</p>
<p align="center">40</p>
<p align="center">39</p>
<p align="center">37</p>
<p align="center">35</p>
<p align="center">34</p>
<p align="center">33</p>
</td>
<td rowspan="2" valign="top">
<p align="center">6</p>
<p align="center">9</p>
<p align="center">12</p>
<p align="center">15</p>
<p align="center">17</p>
<p align="center">19</p>
<p align="center">21</p>
<p align="center">24</p>
<p align="center">26</p>
<p align="center">28</p>
<p align="center">29</p>
<p align="center">31</p>
<p align="center">33</p>
<p align="center">35</p>
<p align="center">37</p>
<p align="center">38</p>
<p align="center">40</p>
<p align="center">42</p>
<p align="center">43</p>
<p align="center">45</p>
<p align="center">46</p>
<p align="center">48</p>
<p align="center">49</p>
<p align="center">51</p>
<p align="center">52</p>
<p align="center">54</p>
<p align="center">55</p>
<p align="center">57</p>
<p align="center">58</p>
<p align="center">59</p>
<p align="center">66</p>
<p align="center">73</p>
<p align="center">79</p>
<p align="center">85</p>
<p align="center">91</p>
<p align="center">97</p>
<p align="center">108</p>
<p align="center">118</p>
<p align="center">128</p>
<p align="center">138</p>
</td>
<td rowspan="2" valign="top">
<p> </p>
</td>
<td valign="top">
<p align="center">1.0</p>
<p align="center">1.5</p>
<p align="center">2.0</p>
<p align="center">2.5</p>
<p align="center">3.0</p>
<p align="center">3.5</p>
<p align="center">4.0</p>
<p align="center">4.5</p>
<p align="center">5.0</p>
<p align="center"> </p>
</td>
<td valign="top">
<p align="center">80</p>
<p align="center">108</p>
<p align="center">135</p>
<p align="center">159</p>
<p align="center">182</p>
<p align="center">205</p>
<p align="center">226</p>
<p align="center">247</p>
<p align="center">268</p>
<p align="center"> </p>
</td>
<td valign="top">
<p align="center">80</p>
<p align="center">72</p>
<p align="center">67</p>
<p align="center">64</p>
<p align="center">61</p>
<p align="center">58</p>
<p align="center">57</p>
<p align="center">55</p>
<p align="center">53</p>
<p align="center"> </p>
</td>
<td valign="top">
<p align="center">3</p>
<p align="center">5</p>
<p align="center">6</p>
<p align="center">7</p>
<p align="center">8</p>
<p align="center">9</p>
<p align="center">9</p>
<p align="center">10</p>
<p align="center">11</p>
<p align="center"> </p>
</td>
</tr>
<tr>
<td colspan="4" valign="top"><strong> </strong>
<p><strong>Source from Haskins SC. A simple fluid therapy planning guide. <em>Semin Vet Med Surg (Small Anim)</em> 3:232. 1988</strong></p>
<strong> </strong>
<p><strong>* *Nutritional requirements of the cat. National Research Council. Bethesda, MD. 1985</strong></p>
</td>
</tr>
<tr>
<td colspan="4" valign="top"><strong> </strong>
<p><strong>Source from Haskins SC. A simple fluid therapy planning guide. <em>Semin Vet Med Surg (Small Anim)</em> 3:232. 1988</strong></p>
<strong> </strong>
<p><strong>* Nutritional requirements of the dog. National Research Council. Bethesda, MD. 1985</strong></p>
</td>
<td valign="top"></td>
<td valign="top"></td>
<td valign="top"></td>
<td valign="top"></td>
<td valign="top"></td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">2002 Treatment Protocol for Canine Parvo Virus:</span></strong></p>
<p align="center">This is the <em>"Ideal General Approach"</em> to cases - Remember<span style="text-decoration: underline;"> this is</span> a "<em><span style="text-decoration: underline;">biological system</span></em>" so be flexible!!!!!!!!</p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>At admission </strong></p>
</td>
<td valign="middle">
<p align="justify">Place IV catheter / IV amoxycillin / Ht / TSP/glucose/KReplacement fluid with 20 meq. KCL(1 vial) + 20 ml 50% dextrose in 1l ringer lactate.</p>
<p align="justify">[<em>This gives a 1% dextrose solution</em> - "Maintelyte with glucose 5%" glucose to high for rehydration and causes glycosuria]</p>
<p align="justify">Pain killers for abdominal pain – synthetic opioids (duprenophine / butorphanol).</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>1<sup>st</sup> 2 hours </strong></p>
</td>
<td valign="middle">
<p align="justify">Work out the sum of rehydration + Maintenance (off table) for 1<sup>st</sup> 12 hoursGive ¼ to ½ of amount over first 2 hours to correct intra-vascular volume and blood pressure (warm fluids to body temp).</p>
<p align="justify">If in shock – apply first principles for shock therapy.</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>After 1<sup>st</sup> 2 hrs </strong></p>
</td>
<td valign="middle">
<p align="justify">Give rest of fluid over next 10 hours. Test Ht + TSP + K + GlucoseWarm patient on heating pad at this point [<strong>NB – not before</strong> as peripheral vascular dilation progresses shock!]</p>
<p align="justify">(Spike drip with more glucose if needed. [50ml 50% dextrose =2.5% or 100ml 50% dextrose in 1 litre = 5%]</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>2-3 hrs </strong></p>
</td>
<td valign="middle">
<p align="justify">Metoclopramide either as an I.V. bolus or a constant rate infusion (CRI) - to treat ileus and/or vomiting</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>4 - 5 hrs. </strong></p>
</td>
<td valign="middle">
<p align="justify">Start to feed (aim for at least 1/3 of requirements over next 24 hours)</p>
<p align="justify">Work out requirements with formula – [(bwx30) +70] x illness factor (1.25 – 1.5)</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>12 hrs. </strong></p>
</td>
<td valign="middle">
<p align="justify">Re-assess hydration: continue rehydrating or change to</p>
<p align="justify">1 to 1 ½ x maintenance fluid rate .</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>12 hrs </strong></p>
</td>
<td valign="middle">
<p align="justify">Gentamicin IV once patient is rehydrated to cover gram-negative bacteria.</p>
<p align="justify"><em>(check for urine filling of the bladder, CRT&lt;2 sec’s)</em></p>
</td>
</tr>
</tbody>
</table>
<p><em>(Published- September 2002, courtesy of Dr D Miller)</em></p></div><div class="feed-description"><p align="center">PARVO VIRAL DIARRHOEA</p>
<p>These guidelines for Parvo virosis (or any very ill puppy with severe acute diarrhoea) were compiled by members of and are currently in use at Onderstepoort<strong><em> </em></strong>in the Section of Small Animal Medicine, Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria.</p>
<p>Compiled by: Dr. Dave Miller <a href="mailto:dmiller@op.up.ac.za">dmiller@op.up.ac.za</a> P/Bag X 04, Onderstepoort, 0110, SA</p>
<p><strong><span style="text-decoration: underline;">
<p>Introduction:</p>
</span></strong></p>
<p>Acute diarrhoea is second only to pruritus in prevalence in dogs presented to veterinarians. There is, however, a large difference in the pathophysiology and the consequences between a " run of the mill acute diarrhoea" and a puppy suffering from parvo viral diarrhoea.</p>
<p>Until recently we have treated all acute diarrhoea cases alike! No food until the vomiting and diarrhoea have stopped and then small amounts of low fat foods if the dog would eat voluntarily. This implies that many of these young puppies would go 3-10 days without food!</p>
<p>Over the years advances have occurred in the fields of pain control, fluid administration, antibiotic therapy and basic care of these patients. There has also been a paradigm shift in our thinking towards feeding! We have recognised that puppies with <em>parvo</em> are not just acute diarrhoea cases and not only must we feed them as soon as possible, but if they do not eat on their own, we should tube feed them!</p>
<p>Table1: Normal physiology of the small intestines.</p>
<table border="1" cellspacing="1" cellpadding="7" width="568">
<tbody>
<tr>
<td valign="top"><strong>
<p>The Mucosal lining of the GIT.</p>
</strong>
<p>The intestinal epithelial cells carry out a multitude of functions:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Villus crypts: function primarily to secrete fluid into the bowel.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">After division, the cells migrate up the villus from the crypt reaching the tip in 3-5 days. During migration, the cells mature and change their primary function from secretion to surface digestion and absorption.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Villus tip: carries out final stages of protein and carbohydrate digestion together with absorption of nutrients, salts and water.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Normal mucosal integrity and function are usually restored in 2-3 days, provided the inciting cause is eliminated and the initial insult was not sufficiently severe to damage the crypts.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Rapid cell turnover is the major reason why most <strong>acute</strong> diseases of the small intestine are self-limiting.</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">
<p>Acute Small Intestinal Diarrhoea.</p>
</span></strong></p>
<p>This is an otherwise healthy dog that has diarrhoea. The dog has an acute onset of diarrhoea with or without vomiting and the dog may or may not be depressed (e.g. overeating, garbage disease [preformed toxin], diet change etc.).</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Abrupt onset diarrhoea that has a short clinical course that ranges from transient and self-limiting to fulminating and explosive.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Typical treatment of acute diarrhoea:</td>
</tr>
</tbody>
</table>
<p>Needs only <strong>supportive and symptomatic therapy,</strong> since most animals that die from diarrhoea do so not as a result of the inciting cause but from the loss of electrolytes and water, with subsequent <span style="text-decoration: underline;">dehydration</span>, acidosis and shock.</p>
<p><strong><span style="text-decoration: underline;">
<p>Non-specific, symptomatic treatment of acute diarrhoea:</p>
</span></strong></p>
<p>In cases, where foreign bodies and systemic diseases causing the diarrhoea have been ruled out, treatment may not always be indicated as many animals improve spontaneously in a day or two without treatment.</p>
<p>General treatment measures (if needed) include:</p>
<p>- Dietary restriction 6- 12 hours (preferably not longer in young puppies or toy breeds).</p>
<p>(Dogs over 4-6 months can go 12-20 hours without food.)</p>
<p>- Maintenance of fluid and electrolyte levels and acid-base homeostasis.</p>
<p>- Rarely anti-bacterials</p>
<p>- Anti-emetics</p>
<p><strong>
<p>Anti-emetics</p>
</strong></p>
<p>PLEASE DON’T LET THEM VOMIT!!!!!!!!!!!!!!</p>
<p>Once FB ruled out – dispense metoclopramide (0.2-0.5 mg/kg po or sc Tid/Qid)</p>
<p><strong>
<p>Dietary Restriction:</p>
</strong></p>
<p>- Rest the GI tract. Withhold food 6-12 hours (or more).</p>
<p>Biological system -Toy breed puppy 4-6 hours, adult Staffie 6 - 18h.</p>
<p>- Feed small, bland meals frequently when resume feeding (as soon as possible)</p>
<p>[We use commercial intestinal diets]</p>
<p>- Gradually convert to regular commercial puppy/adult food over 2-3 days once the</p>
<p>diarrhoea resolves.</p>
<p>Antibacterials: (For acute diarrhoea in non-collapsed dog)</p>
<p>Antibiotics have long been part of standard treatment of acute and chronic diarrhoea; yet there is no evidence for bacterial infection as a major cause of diarrhoea in small animals. Therefore, there is little or no indication for the routine use of oral antimicrobials in the treatment of diarrhoea in small animals.</p>
<p>Antibiotics are <strong>only</strong> <strong>indicated</strong> when extensive damage to the intestinal mucosal barrier occurs. Mucosal damage is thought to allow penetration of the intestinal wall by bacteria with subsequent entry into the systemic circulation. The following findings indicate the need for antibacterial therapy.</p>
<p>- Fever</p>
<p>- Collapse</p>
<p>- Left shift neurophilia with or without degenerative or toxic neutrophil changes.</p>
<p>- Haemorrhagic diarrhoea</p>
<table border="1" cellspacing="1" cellpadding="7" width="538">
<tbody>
<tr>
<td valign="top">
<p align="left">Normal intestinal flora are protective of the host, inhibiting colonisation by pathogenic organisms. The disruption of bacterial flora exposes the host to more pathogenic processes and may prolong the return of normal intestinal function and homeostasis.</p>
</td>
</tr>
</tbody>
</table>
<p><strong>
<p>Fluid therapy:</p>
</strong></p>
<p>Mild dehydration often causes anorexia.</p>
<p>Unless the patient needs i.v. fluids, we often give 5% rehydration fluids sub-cutaneously or intra-peritonealy and the patient is sent home.</p>
<p>[BW x 5% x 10 = fluid (ml) administered]</p>
<p><strong><span style="text-decoration: underline;">
<p>WHAT ABOUT PARVO?</p>
</span></strong></p>
<p>Parvo virus colonises fast-dividing cell lines and through it’s replication process, destroys them. The typical parvo puppy thus loses:</p>
<p>- its bone marrow, lymphoid tissue and the enterocytes lining the GIT.</p>
<p>So one is left with an immunocompromised dog which is likely to develop septicaemia from enteric bacteria.</p>
<p>2002: Treatment Protocol for Canine Parvo Virus:</p>
<p>This is the <em>"Ideal General Approach"</em> to cases - Remember<span style="text-decoration: underline;"> this is</span> a "<em><span style="text-decoration: underline;">biological system</span></em>" so be flexible!!!!!!!!</p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>At admission</strong></p>
</td>
<td valign="middle">
<p align="justify">Place IV catheter / IV amoxycillin / Ht / TSP/glucose/K</p>
<p align="justify">Replacement fluid with 20 meq. KCL(1 vial) + 20 ml 50% dextrose in 1l ringer lactate.</p>
<p align="justify">[<em>This gives a 1% dextrose solution</em> - <em>"Maintelyte with glucose 5%" glucose to high for rehydration and causes glycosuria]</em></p>
<p align="justify">Pain killers for abdominal pain – synthetic opioids (Temgesic).</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>1<sup>st</sup> 2 hours</strong></p>
</td>
<td valign="middle">
<p align="justify">Work out the sum of re-hydration + Maintenance (off table) for 1<sup>st</sup> 12 hours</p>
<p align="justify">Give ¼ to ½ of amount over first 2 hours to correct intra-vascular volume and blood pressure (warm fluids to body temp).</p>
<p align="justify">If in shock – apply first principles for shock therapy.</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>After 1<sup>st</sup> 2 hrs</strong></p>
</td>
<td valign="middle">
<p align="justify">Give rest of fluid over next 10 hours. Test Ht + TSP + K + Glucose</p>
<p align="justify">Warm patient on heating pad at this point [<strong>NB – not before</strong> as progresses shock!]</p>
<p align="justify">(Spike drip with more glucose if needed. [50ml 50% =2.5% or 100ml 50% = 5%]</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>2-3 hrs</strong></p>
</td>
<td valign="middle">
<p align="justify">Metoclopramide either as an I.V. bolus or a constant rate infusion (CRI) - to treat ileus and/or vomiting (doses later in the document).</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx. 4 - 5 hrs.</strong></p>
</td>
<td valign="middle">
<p align="justify">Start to feed (aim for at least 1/3 of requirements over next 24 hours)</p>
<p align="justify">Work out requirements with formula – [(bwx30) +70] x illness factor (1.25 – 1.5)</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx. 12 hrs.</strong></p>
</td>
<td valign="middle">
<p align="justify">Re-assess hydration: continue rehydrating or change to</p>
<p align="justify">1 to 1 ½ x maintenance rate</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx. 12 hrs</strong></p>
</td>
<td valign="middle">
<p align="justify">Gentamicin IV if patient is rehydrated to cover gram-negative bacteria.</p>
<em> </em>
<p align="justify"><em>(check for urine in bladder, CRT&lt;2 sec’s) </em></p>
</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">
<p align="justify">Monitoring the Parvo puppy.</p>
</span></strong></p>
<p align="justify">The following <span style="text-decoration: underline;">should</span> ideally be monitored at admission, after 2 hours of fluids and then on a daily basis <strong>in patients that are still ill</strong>:</p>
<p align="center">USE PAEDIATRIC SAMPLING TUBES OR TAKE VERY SMALL QUANTITIES OF BLOOD.</p>
<p align="left">Fluid Therapy</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Rehydration</td>
</tr>
</tbody>
</table>
<p align="justify">- Body mass x 10 x % dehydration = volume in ml (give over 12 hours)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Maintenance</td>
</tr>
</tbody>
</table>
<p align="justify">- Refer to fluid tables!!!! (appended at the end)</p>
<p align="justify">(The formula 40 – 60 ml/kg/24 hours is <strong>not valid</strong> in patients under 10 kg)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Ongoing losses</td>
</tr>
</tbody>
</table>
<p align="justify">Estimated at 10 – 20 ml/kg/24 Hrs (if still vomiting and diarrhoea)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Fluid Selection</td>
</tr>
</tbody>
</table>
<p align="justify">Calculate the re-hydration + maintenance + ongoing losses for first 12 hours and then rehydrate with:</p>
<table border="1" cellspacing="1" cellpadding="7" width="362">
<tbody>
<tr>
<td valign="top">
<p align="justify"> </p>
</td>
</tr>
</tbody>
</table>
<p align="center"><strong>è ¼ - ½ over first 2 hours then rest over 10 hours (check K infusion rates)</strong></p>
<p align="justify">Only once rehydration is achieved can maintenance fluids be used:</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Decision dependant on patient condition.</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">You should ideally place a central catheter.</td>
</tr>
</tbody>
</table>
<p align="justify">Short notes on spiking drips.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Always label drip bag!</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Never give potassium (K) as a bolus!</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Supplement K as shown in the table below <strong>only after rehydration is complete! </strong>Potassium given too fast is cardiotoxic</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<p align="justify">– do not exceed 0.5meq of K /kg/h</p>
</table>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td colspan="3" valign="top">
<p align="center">POTASSIUM SUPPLEMENTATION (1 vial KCL 15 % = 20mEq)</p>
</td>
</tr>
<tr>
<td valign="top">
<p>Serum Potassium mEq/l of patient</p>
</td>
<td valign="top">
<p>Supplementation potassium (per 1000ml ) replacement fluid</p>
<p><strong>(mmol KCL = meq K<sup>+</sup>)</strong></p>
</td>
<td valign="top">
<p>MAXIMAL FLUID INFUSION RATE</p>
<p>(ml/kg/h)</p>
</td>
</tr>
<tr>
<td valign="top">
<p>3.5 – 5.5 (Normal)</p>
</td>
<td valign="top">
<p>20 mEq K (1 vial of 15%)</p>
</td>
<td valign="top">
<p>25</p>
</td>
</tr>
<tr>
<td valign="top">
<p>3.0 – 3.4</p>
</td>
<td valign="top">
<p>30 mEq K</p>
</td>
<td valign="top">
<p>18</p>
</td>
</tr>
<tr>
<td valign="top">
<p>2.5 – 2.9</p>
</td>
<td valign="top">
<p>40 mEq K</p>
</td>
<td valign="top">
<p>12</p>
</td>
</tr>
<tr>
<td valign="top">
<p>2.0 – 2.4</p>
</td>
<td valign="top">
<p>60 mEq K</p>
</td>
<td valign="top">
<p>8</p>
</td>
</tr>
<tr>
<td valign="top">
<p>&lt;2.0</p>
</td>
<td valign="top">
<p>80 mEq K</p>
</td>
<td valign="top">
<p>6</p>
</td>
</tr>
</tbody>
</table>
<p align="justify"><strong><span style="text-decoration: underline;">Antibiotic Therapy.</span></strong></p>
<p align="justify">Need to cover gram negative and positive as well as aerobic and anaerobic bacteria. The following antibiotics can be used:Amoxycillin - Amoxil 15 – 20 mg/kg IV TIDthen- penicillin’s p.o. s.c. i.v. 20 mg/kg BID(Change over when perfusion is deemed to be GOOD)Gentamicin - 3 mg/kg TID or 5 mg/kg BID, once patient is rehydrated</p>
<p align="justify"><strong>Bladder filling with urine shows rehydration and renal</strong> perfusion.</p>
<p align="justify">- Use until patient is clinically improved- 3-5 days max. (Not all patients will need Genta)Enrofloxacin - 2.5mg/kg BID IM/SC</p>
<p align="justify">used when gentamicin is contraindicated)</p>
<p align="justify"><strong>OWNER CONSENT IS NECESSARY!</strong></p>
<p align="justify">Avoid in large breeds - cartilage damage.</p>
<p align="justify"><strong>Nutrition.</strong></p>
<p align="justify"><strong><em>The previous "NIL PER OS"</em> <em>is not followed anymore!!</em></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Start to feed once rehydration is underway (+/- 4-12 hours after admission)</td>
</tr>
</tbody>
</table>
<p align="justify">(We try to never starve a puppy for longer than 6 hours once in hospital)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If possible aim for a minimum of 1/3 of nutritional requirements over next 24 hours</td>
</tr>
</tbody>
</table>
<p align="justify">([Body weight x 30] + 70) x illness factor. 1.25 -1.5 depending on clinical findings.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">If still vomiting a lot, miss out 1-2 hours, cut back slightly on quantity but do not starve!</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Naso-oesophageal tube: can be placed at admission or 4-6 hours later.</td>
</tr>
</tbody>
</table>
<p align="justify">Information on Kcal/ml of some of the commonly fed foods formulated for this purpose in the isolation unit can be obtained from <span style="text-decoration: underline;">Council’s office.</span></p>
<p align="justify">We send them home with the 800gram Intestinal formula puppy food bags and instructions to feed only that for at least 3-7 days.</p>
<p align="justify"><strong><span style="text-decoration: underline;">Additional Therapy if Required:</span></strong></p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<strong></strong>
<tbody>
<tr>
<td width="42" valign="baseline"><strong></strong></td>
<td width="100%" valign="top"><strong><span style="text-decoration: underline;"> Anti-emetics </span></strong></td>
</tr>
</tbody>
</table>
<p><strong></strong></p>
<p align="justify">Metoclopramide - first iv or sc and see the effect, if still vomiting, we use a CRI- 0.2 -0.4 mg/kg q6-8 hrly (iv/sc/im)- 1-2 mg/kg/day as a Constant rate infusion(CRI)<span style="text-decoration: underline;"><strong><em>Prochlorpronazine</em></strong> </span>- 0.5 mg/kg im/sc q 8 hrly</p>
<p align="justify">(No prokinetic effect)</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Plasma transfusion - 20 ml/kg if albumin <strong>&lt; 20 g/dl</strong></td>
</tr>
</tbody>
</table>
<p align="justify">or - TSP &lt; 40.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Blood transfusion to be administered if the patient is not improving and/or the Ht &lt;15–20.</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Hetastarch – 5-20 ml/kg bolus when patient is not improving but pain is controlled and the Ht, potassium, glucose and albumin levels are normal.</td>
</tr>
</tbody>
</table>
<p align="justify">In cases "not doing well" we use a constant rate infusion (CRI) of ½-2 ml/kg/h.</p>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Deworm – 1ml/kg panacur OID P.O. 5 d. (If vomiting – Ivomec - need owner consent)</td>
</tr>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Temgesic 0.01mg/kg iv 6 hrly if <strong>ANY</strong> abdominal pain (need only a few treatments)</td>
</tr>
</tbody>
</table>
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tbody>
<tr>
<td width="42" valign="baseline"></td>
<td width="100%" valign="top">Sucrulfate 1ml/3kg q6-8 hrly if dogs vomiting a lot (for reflux oesophagitis)</td>
</tr>
</tbody>
</table>
<p align="justify">Cimetidine 10 mg/kg I.V. TID or Ranitidine 2 mg/kg BID I.V.</p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td valign="top">
<p align="justify"><strong>NB: ALL NSAIDs ESPECIALLY THE OLDER PRODUCTS LIKE PHENYLBUTAZONE, AND FLUNIXIN MEG. ARE NEPHROTOXIC AND CAUSE GASTRIC ULCERS AND MUST BE AVOIDED IN ALL DOGS AND CATS WITH LOW BLOOD PRESSURE.</strong></p>
<p align="center">[e.g. general anaesthesia, diarrhoea, vomiting, heat stroke, hit by car, Babesiosis, shock etc.]</p>
</td>
</tr>
</tbody>
</table>
<p align="center"><strong>DAILY WATER REQUIREMENTS FOR DOGS AND CATS</strong></p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td colspan="4" valign="top"><strong> </strong>
<p align="center"><strong>Daily Water</strong></p>
<strong> </strong>
<p align="center"><strong>Requirements for the Dog*</strong></p>
</td>
<td valign="top"></td>
<td colspan="4" valign="top"><strong> </strong>
<p align="center"><strong>Daily Water</strong></p>
<strong> </strong>
<p align="center"><strong>Requirements for the Cat**</strong></p>
</td>
</tr>
<tr>
<td valign="top"><strong> </strong>
<p align="justify"><strong><br /></strong></p>
<strong> </strong>
<p align="justify"><strong>Body weight</strong></p>
<strong> </strong>
<p align="center"><strong>(kg)</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong>TOTAL</strong></p>
<strong> </strong>
<p align="center"><strong>WATER</strong></p>
<strong> </strong>
<p align="center"><strong>ml/day</strong></p>
</td>
<td valign="top"><strong> </strong>
<p><strong>/kg</strong></p>
</td>
<td valign="top"><strong> </strong>
<p><strong>/h</strong></p>
</td>
<td valign="top"></td>
<td valign="top"><strong> </strong>
<p align="center"><strong><br /></strong></p>
<strong> </strong>
<p align="center"><strong>Bodyweight</strong></p>
<strong> </strong>
<p align="center"><strong>(kg)</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong>TOTAL</strong></p>
<strong> </strong>
<p align="center"><strong>WATER</strong></p>
<strong> </strong>
<p align="center"><strong>ml/day</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong><br /></strong></p>
<strong> </strong>
<p align="center"><strong>/kg</strong></p>
</td>
<td valign="top"><strong> </strong>
<p align="center"><strong>/h</strong></p>
</td>
</tr>
<tr>
<td rowspan="2" valign="top">
<p align="center">1</p>
<p align="center">2</p>
<p align="center">3</p>
<p align="center">4</p>
<p align="center">5</p>
<p align="center">6</p>
<p align="center">7</p>
<p align="center">8</p>
<p align="center">9</p>
<p align="center">10</p>
<p align="center">11</p>
<p align="center">12</p>
<p align="center">13</p>
<p align="center">14</p>
<p align="center">15</p>
<p align="center">16</p>
<p align="center">17</p>
<p align="center">18</p>
<p align="center">19</p>
<p align="center">20</p>
<p align="center">21</p>
<p align="center">22</p>
<p align="center">23</p>
<p align="center">24</p>
<p align="center">25</p>
<p align="center">26</p>
<p align="center">27</p>
<p align="center">28</p>
<p align="center">29</p>
<p align="center">30</p>
<p align="center">35</p>
<p align="center">40</p>
<p align="center">45</p>
<p align="center">50</p>
<p align="center">55</p>
<p align="center">60</p>
<p align="center">70</p>
<p align="center">80</p>
<p align="center">90</p>
<p align="center">100</p>
<p align="center"> </p>
</td>
<td rowspan="2" valign="top">
<p align="center">132</p>
<p align="center">214</p>
<p align="center">285</p>
<p align="center">348</p>
<p align="center">407</p>
<p align="center">463</p>
<p align="center">515</p>
<p align="center">566</p>
<p align="center">615</p>
<p align="center">662</p>
<p align="center">707</p>
<p align="center">752</p>
<p align="center">795</p>
<p align="center">837</p>
<p align="center">879</p>
<p align="center">919</p>
<p align="center">959</p>
<p align="center">998</p>
<p align="center">1037</p>
<p align="center">1075</p>
<p align="center">1112</p>
<p align="center">1149</p>
<p align="center">1185</p>
<p align="center">1221</p>
<p align="center">1256</p>
<p align="center">1291</p>
<p align="center">1326</p>
<p align="center">1360</p>
<p align="center">1394</p>
<p align="center">1427</p>
<p align="center">1590</p>
<p align="center">1746</p>
<p align="center">1896</p>
<p align="center">2041</p>
<p align="center">2182</p>
<p align="center">2319</p>
<p align="center">2583</p>
<p align="center">2836</p>
<p align="center">3080</p>
<p align="center">3316</p>
</td>
<td rowspan="2" valign="top">
<p align="center">132</p>
<p align="center">107</p>
<p align="center">95</p>
<p align="center">87</p>
<p align="center">81</p>
<p align="center">77</p>
<p align="center">74</p>
<p align="center">71</p>
<p align="center">68</p>
<p align="center">66</p>
<p align="center">64</p>
<p align="center">63</p>
<p align="center">61</p>
<p align="center">60</p>
<p align="center">59</p>
<p align="center">57</p>
<p align="center">56</p>
<p align="center">55</p>
<p align="center">55</p>
<p align="center">54</p>
<p align="center">53</p>
<p align="center">52</p>
<p align="center">52</p>
<p align="center">51</p>
<p align="center">50</p>
<p align="center">50</p>
<p align="center">49</p>
<p align="center">49</p>
<p align="center">48</p>
<p align="center">48</p>
<p align="center">45</p>
<p align="center">44</p>
<p align="center">42</p>
<p align="center">41</p>
<p align="center">40</p>
<p align="center">39</p>
<p align="center">37</p>
<p align="center">35</p>
<p align="center">34</p>
<p align="center">33</p>
</td>
<td rowspan="2" valign="top">
<p align="center">6</p>
<p align="center">9</p>
<p align="center">12</p>
<p align="center">15</p>
<p align="center">17</p>
<p align="center">19</p>
<p align="center">21</p>
<p align="center">24</p>
<p align="center">26</p>
<p align="center">28</p>
<p align="center">29</p>
<p align="center">31</p>
<p align="center">33</p>
<p align="center">35</p>
<p align="center">37</p>
<p align="center">38</p>
<p align="center">40</p>
<p align="center">42</p>
<p align="center">43</p>
<p align="center">45</p>
<p align="center">46</p>
<p align="center">48</p>
<p align="center">49</p>
<p align="center">51</p>
<p align="center">52</p>
<p align="center">54</p>
<p align="center">55</p>
<p align="center">57</p>
<p align="center">58</p>
<p align="center">59</p>
<p align="center">66</p>
<p align="center">73</p>
<p align="center">79</p>
<p align="center">85</p>
<p align="center">91</p>
<p align="center">97</p>
<p align="center">108</p>
<p align="center">118</p>
<p align="center">128</p>
<p align="center">138</p>
</td>
<td rowspan="2" valign="top">
<p> </p>
</td>
<td valign="top">
<p align="center">1.0</p>
<p align="center">1.5</p>
<p align="center">2.0</p>
<p align="center">2.5</p>
<p align="center">3.0</p>
<p align="center">3.5</p>
<p align="center">4.0</p>
<p align="center">4.5</p>
<p align="center">5.0</p>
<p align="center"> </p>
</td>
<td valign="top">
<p align="center">80</p>
<p align="center">108</p>
<p align="center">135</p>
<p align="center">159</p>
<p align="center">182</p>
<p align="center">205</p>
<p align="center">226</p>
<p align="center">247</p>
<p align="center">268</p>
<p align="center"> </p>
</td>
<td valign="top">
<p align="center">80</p>
<p align="center">72</p>
<p align="center">67</p>
<p align="center">64</p>
<p align="center">61</p>
<p align="center">58</p>
<p align="center">57</p>
<p align="center">55</p>
<p align="center">53</p>
<p align="center"> </p>
</td>
<td valign="top">
<p align="center">3</p>
<p align="center">5</p>
<p align="center">6</p>
<p align="center">7</p>
<p align="center">8</p>
<p align="center">9</p>
<p align="center">9</p>
<p align="center">10</p>
<p align="center">11</p>
<p align="center"> </p>
</td>
</tr>
<tr>
<td colspan="4" valign="top"><strong> </strong>
<p><strong>Source from Haskins SC. A simple fluid therapy planning guide. <em>Semin Vet Med Surg (Small Anim)</em> 3:232. 1988</strong></p>
<strong> </strong>
<p><strong>* *Nutritional requirements of the cat. National Research Council. Bethesda, MD. 1985</strong></p>
</td>
</tr>
<tr>
<td colspan="4" valign="top"><strong> </strong>
<p><strong>Source from Haskins SC. A simple fluid therapy planning guide. <em>Semin Vet Med Surg (Small Anim)</em> 3:232. 1988</strong></p>
<strong> </strong>
<p><strong>* Nutritional requirements of the dog. National Research Council. Bethesda, MD. 1985</strong></p>
</td>
<td valign="top"></td>
<td valign="top"></td>
<td valign="top"></td>
<td valign="top"></td>
<td valign="top"></td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">2002 Treatment Protocol for Canine Parvo Virus:</span></strong></p>
<p align="center">This is the <em>"Ideal General Approach"</em> to cases - Remember<span style="text-decoration: underline;"> this is</span> a "<em><span style="text-decoration: underline;">biological system</span></em>" so be flexible!!!!!!!!</p>
<table border="1" cellspacing="1" cellpadding="7" width="100%">
<tbody>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>At admission </strong></p>
</td>
<td valign="middle">
<p align="justify">Place IV catheter / IV amoxycillin / Ht / TSP/glucose/KReplacement fluid with 20 meq. KCL(1 vial) + 20 ml 50% dextrose in 1l ringer lactate.</p>
<p align="justify">[<em>This gives a 1% dextrose solution</em> - "Maintelyte with glucose 5%" glucose to high for rehydration and causes glycosuria]</p>
<p align="justify">Pain killers for abdominal pain – synthetic opioids (duprenophine / butorphanol).</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>1<sup>st</sup> 2 hours </strong></p>
</td>
<td valign="middle">
<p align="justify">Work out the sum of rehydration + Maintenance (off table) for 1<sup>st</sup> 12 hoursGive ¼ to ½ of amount over first 2 hours to correct intra-vascular volume and blood pressure (warm fluids to body temp).</p>
<p align="justify">If in shock – apply first principles for shock therapy.</p>
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<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>After 1<sup>st</sup> 2 hrs </strong></p>
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<td valign="middle">
<p align="justify">Give rest of fluid over next 10 hours. Test Ht + TSP + K + GlucoseWarm patient on heating pad at this point [<strong>NB – not before</strong> as peripheral vascular dilation progresses shock!]</p>
<p align="justify">(Spike drip with more glucose if needed. [50ml 50% dextrose =2.5% or 100ml 50% dextrose in 1 litre = 5%]</p>
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</tr>
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<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>2-3 hrs </strong></p>
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<p align="justify">Metoclopramide either as an I.V. bolus or a constant rate infusion (CRI) - to treat ileus and/or vomiting</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>4 - 5 hrs. </strong></p>
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<td valign="middle">
<p align="justify">Start to feed (aim for at least 1/3 of requirements over next 24 hours)</p>
<p align="justify">Work out requirements with formula – [(bwx30) +70] x illness factor (1.25 – 1.5)</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>12 hrs. </strong></p>
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<td valign="middle">
<p align="justify">Re-assess hydration: continue rehydrating or change to</p>
<p align="justify">1 to 1 ½ x maintenance fluid rate .</p>
</td>
</tr>
<tr>
<td valign="middle" bgcolor="#ffffff"><strong> </strong>
<p align="justify"><strong>Approx.</strong></p>
<strong> </strong>
<p align="justify"><strong>12 hrs </strong></p>
</td>
<td valign="middle">
<p align="justify">Gentamicin IV once patient is rehydrated to cover gram-negative bacteria.</p>
<p align="justify"><em>(check for urine filling of the bladder, CRT&lt;2 sec’s)</em></p>
</td>
</tr>
</tbody>
</table>
<p><em>(Published- September 2002, courtesy of Dr D Miller)</em></p></div>